After two months, I received the response to my 1st level appeal to BCBS of KS. (The photo to the left would be considered a "covered" item - a sock pulled over a Pringle's can, stuffed in a shoe.)This is what I wrote in my "2nd level appeal." I have to exhaust all my appeals before I have the right to bring civil action. It's just a way to keeping dragging things out hoping I'll go away or get run over by a truck before they have to deal with me.
Thank you for the detailed review of my first level appeal. I can see by your response that you have given this matter a great deal of consideration. Indeed, it took 2 months to generate the following paragraph: [KFG: This is "Sarchasm" - The gulf between the author of sarcastic wit and the person who doesn't get it.]
"The items denied as non-covered were reviewed pre-service and notification was made to you that the micro-processor knee and lithium battery were considered electrical add-on items and were exclusions to the contract. The contract does not specifically indicate the denied items as ‘deluxe’; however, they do fall under the exclusion for charges for electrically operated prosthetic appliances, devices or items. This exclusion applies only to prosthetic items, not durable medical equipment such as a pacemaker, insulin pumps or other items indicated in your appeal. Therefore, the denials are correct."
[KFG: Woo-Hoo! They came right out and admitted that they only discriminate against amputees!]
Thank you for confirming that this exclusion is limited only to prosthetics. Therefore, by default, only amputees are affected by this arbitrary exclusion. That was precisely my point and your confirmation is very informative. While you are correct in that the contract does not use the word “deluxe,” I have several documents from your company and the Kansas State Employee Health Policy Authority that specifically use the word “deluxe” as a reason for denial. The word seems to have found favor since the 2009 State Employee Health Care Contract now denies amputees “deluxe enhancements, electronic components, microprocessors, performance enhancements, comfort, convenience and luxury items.” I’m not certain that there is a CPT code for comfort and convenience, but I can assure you that there is nothing comfortable or convenient about amputation and using a prosthetic limb.
Yada-yada, blah, blah, blah....
So, let me see...around the end of March, first of April, I should get back another thoughtful paragraph that says, "No."
This is beyond obnoxious. I half expect them to come right out and say that you don't "deserve" to do the things everybody else likes to do. "You should be grateful you can still sit and watch other people do things!"
ReplyDeleteShouldn't have mentioned the Pringles can, it might not be covered if the chips are still in it. Not durable, you know.
Actually, the Pringle's Prosthesis would be excluded under the 2009 contract. With the chips, it clearly comes under the heading of "comfort and convenience."
ReplyDeleteDid I mention that penile prostheses are covered? I wonder if that's a "performance enhancement?!"
Wow, that takes... never mind. Kind of a prick to the ego, though. They must be nuts.
ReplyDelete