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Widget Richards got her insurance to cover hearing aids.
She tells us:
1. Look at your Health Plan and see if they cover Home Medical Equipment, Prosthesis,
or Orthopedic, etc...
2. Write a letter when submitting bill for hearing aids.
3. Appeal, Appeal, Appeal, if you get turned down.
As a member of the _________ Health
Plan, I am expressing concern about my Health Policy and why the Health Plan does not
cover my medical condition. I was recently turned down by __________ (name of
insurance company) for an Artificial Ear called a Hearing Aid. Consider this letter
as a formal Appeal.
In the_________ Health Plan on page
__ #__. Audiometry examinations for hearing aids, or hearing aids are NOT COVERED
under the Health Plan but on page __#__ , Home Medical Equipment, Prosthesis,
Orthosis are COVERED under the Health Plan.
Hearing Aids are considered as Home
Medical Equipment, Prosthesis or a Orthosis by the definitions in the ________Health Plan
manual. The Hearing device is a Home Medical Equipment because it is used repeatedly
which is Medically Necessary to improve the functioning of a malformed body member and is
used to prevent further deterioration of the patient's medical condition. A Hearing
aid is a Prosthesis because it is a artificial part, appliance or device used to replace a
missing part of the body. A hearing aid is an Orthopedic appliance or apparatus used
to support, align, and prevent or correct deformities or to improve the function of
movable body parts. Hearing Aids will NEVER restore that body member to 100%
normal functioning, a hearing aid only improves the functioning and helps prevent further
deterioration of other medical conditions. An artificial Arm will never give
that person 100% movement, it only improves the functioning. Leg Braces for a
malformed leg are used only to support, align, prevent or correct deformities or improve
the function of movable body part. There are many more examples!
What is a Hearing Aid?
It is not defined in the _______ Health Plan. If this Home Medical equipment,
Prosthesis or Orthosis (called a Hearing Aid) is recommended by a Physician, it is
considered Medically Necessary. (Put in here your experience without a hearing aid, and
how you are physically and psychologically effected). Any Physician would tell you, if I
went for any long length of time without this device, I would need to seek therapeutic
assistance. The absences of the device could cause further deterioration of my
medical condition which could cause major problems to my neurological and physical well
being.
I would like for you to consider
covering this Medically Necessary Ear Device, which will improve my function at work,
home, etc.... I look forward to your response. |
Barbara
Mellert was successful in getting her insurance company to
cover hearing aids for her 2 children using this letter from their
pediatrician.
Dear Sir/Madam:
I am the primary care pediatrician for ____ and ____ and have been for the
past three years. I worked with their parents, day care providers and the
department of Audiology here at ____ to determine that both boys have
sensorineural hearing loss. ____'s loss is about __ dB, ____'s appears to be
__ dB. Both have benefited immensely from hearing aids. ____ has had his aids
since ____, ____ since ____. In addition to the services provided by the
Audiology Department, they have been receiving early intervention services
from the ____ School District (for ____) and the Early Intervention Services
(for ____).
When emphasis is placed in medical care on detecting major conditions and then
no support is provided for their treatment, effective care is compromised. The
situation for young children is very different for older adults with hearing
loss. Their future adult productivity hinges on effectively gaining
communication skills at a developmentally appropriate stage.
Their hearing aids are a medical necessity; there is no pharmacologic or
surgical treatment available to them. Their hearing aids are the only
"treatment" at this point. The use of hearing aids has greatly
enhanced their development, both educationally and socially, and they minimize
many of the other effects of the hearing loss in the speech, language and
educational areas. I am deeply concerned that Blue Choice chooses not to cover
hearing aides for these young children.
I strongly urge Blue Choice to pay for their hearing aids and associated
hardware (most notably, the ear molds) for the ____ children. The ____ are a
middle income family - having the additional expense this year of two sets of
hearing aids (at approximately ______ per pair) and the new ear molds
approximately every three months (4 times/yearly x 2 boys x $__ = $___) has
proven to be difficult financially.
I welcome the opportunity to discuss this situation further with you and hope
you will cover these necessary medical services.
Sincerely,
__________, MD |
Barb sends us this letter her
doctor wrote:
| To whom it may concern:
I am writing to corroborate the medical necessity of hearing aids
and personal FM hearing system for one of my patients, (name of
patient).
Our Audiological testing of "Patient's name" here at the
University of ______has determined that "patient" has
sensorineural hearing loss. She has benefited immensely from her use
of hearing aids since January, 1995. In addition to the services
provided by the Audiology Department, "patient" has been
receiving special education services for the deaf and hard of hearing
at A_____ County School District.
Hearing aids and a personal FM amplification system are a medical
necessity for "Patient" - there are no pharmacological or
surgical treatments available to improve her hearing. The use of
hearing aids and an FM amplification system have greatly enhanced
"Patient's" speech and language development, as well as
improved her educational performance and social integration.
The FM amplification system should have the following features:
- A transmitter that will allow optimization of speech
intelligibility by allowing "patient" to select
directionality (wide-angle to zoom amplification coverage).
- The transmitter should also allow for direct connection to
audiovisual equipment such as public address systems, televisions,
video recorders, movie projectors, etc.
- The system should have audio-boots that connect directly onto
personal hearing aids.
- The system should allow for total freedom of mobility without
wires or a box that would inhibit movement.
- The system should be compatible with indoor and outdoor use,
with an operating range of approximately 10-15 meters.
- Of course, it should have safety features such as a soft squelch
that automatically cuts off the system when the transmitter is out
of range or if outside interference noise reaches an unacceptable
level.
Ideally, this system will be used in all of "Patient's"
activities and environments, in order to maintain a consistent sound
quality. This feature improves speech and language development.
Sensorineural hearing loss is quite different for a child vs. the
more common presentation in an elderly adult. A child's social and
educational integration is dependent upon speech and language
development. Development of effective communication skills at a
developmentally appropriate age is essential for social integration
and a productive adult life. I welcome the opportunity to discuss
"Patient's" situation further with you, and hope you will
support these necessary medical services. |
Richard gave us permission to put up this letter he wrote:
| Claims Administrator:
As a member of the above referenced Health Plan, I am expressing
concern about my Health Policy and why the Health Plan does not cover
my medical condition. The Claims Administrator recently turned me down
for an Artificial Ear called a Hearing Aid. Consider this letter as a
formal appeal.
The following definition is given on page 7 of the Summery of
Benefits:
Home Medical Equipment -- equipment designed for repeated
use which is medically necessary to treat an illness or injury, to
improve the functioning of a malformed body member, or to prevent
further deterioration of the patient's medical condition. Home
Medical Equipment includes items such as wheelchairs, Hospital beds,
respirators, and other items that the Claims Administrator determines
are Home Medical Equipment.
On page 27 item 4 it clearly states that there are no benefits
provided for hearing aids. However, on page 21 under Prosthetic
Appliances and Home Medical Equipment the following is found:
"benefits are provided for prosthetic appliances, e.g.
artificial limbs and eyes and their fitting...and other Home Medical
Equipment..."
Home Medical Equipment is defined on page 7 as:
"equipment designed for the repeated use which is medically
necessary to treat an illness or injury, to improve the functioning
of a malformed body member, or to prevent further deterioration of
the patient's medical condition..."
Illness is defined by Merriam-Webster's as "an unhealthy
condition of bo9dy or mind." They also define injury as, "an
act that damages or hurts."
Prosthetics are defined by Merriam-Webster's as, "an
artificial device to replace a missing part of the body."
An argument could be made that hearing aids do not come under the
pure definition of a prosthetic device. But the Summary of Benefits
broadens the meaning to include other items such as orthopedic braces,
but then puts limits on other items such as orthopedic shoes. It is
clearly the intent of <name of insurance company> as stated in
the last sentence on page 22 under the heading of Prosthetic
Appliances & Home Medical Equipment to items that are
"medical in nature." Hearing aids do fall under
"medical in nature." The AMA has long taken the position
that deafness and hearing loss are medical problems that can be
remedied medically.
Therefore, according to the above, hearing aids are considered Home
Medical Equipment because they are used repeatedly which is medically
necessary to improve the functioning of a malformed body member and is
used to prevent further deterioration of the patient's medical
condition. Hearing aids will never restore that body member to 100%
normal functioning, a hearing aid only improves the functioning and
helps prevent further deterioration of other medical conditions.
<personal parts deleted> The stress I suffer due to my
hearing loss has been tremendous. My hearing aids are medically
necessary to improve the functioning of my ears, and are used to help
prevent further physical problems created from the stress of
interacting with others.
It is a fact, when my ear devices are broken I suffer serious
physical and psychological medical problems. Any physician would tell
you, if I went for any length of time without my devices, I would need
to seek therapeutic assistance. The absences of the devices cause
further deterioration of my medical condition and causes major
problems to my neurological and physical well being. Many studies have
documented the relationship of hearing loss and declining health. I am
certain were you to suffer a severe hearing loss you would readily
agree it has an effect on your physical health. Hearing is not a
luxury but a necessity for sound physical health for any person that
has grown up as a hearing person.
If a Physician recommends a Home Medical Equipment of Prosthesis
called a "Hearing Aid", it is considered "medically
necessary." It is understood on page 28 under Medical Necessity
Exclusion that what is determined to be "medically
necessary" is at the sole discretion of the Claims Administrator.
Therefore, while hearing aids are excluded they can be included at the
discretion of the Claims Administrator.
I would like for you to consider covering this "medically
necessary" ear device, which will improve my functioning at work
and home, and help me maintain over all physical health.
Sincerely,
|
Trish sent us these 4 letters from her battle to get
hearing aids for her son:
Re: Written Appeal Pursuant to LSA Certificate of
Coverage Complaint and Grievance Procedure
Dear Ms. X,
I am writing this letter to express my concern over the decision by my
health plan, UK-HMO, to deny coverage for the purchase of hearing
appliances (hearing aids) for my son. Please consider this letter a
formal appeal of this decision.
In our phone conversation of Monday, December 4, 2000, you indicated
that hearing aids were not a covered benefit as they are defined as
medical devices and, as such, are excluded from coverage. I have
reviewed the LSA certificate of coverage (COC) benefit booklet in detail
and submit the following for your consideration.
I. The COC does not define a hearing aid. However, you indicated that
the plan considers a hearing aid a medical device. The COC lists devices
under Exclusion and Limitations as "contraceptive devices, therapeutic
devices, health appliances, hypodermic needles or similar items."
I respectfully argue that a hearing aid is in no way similar to the
items listed in this section.
II. The COC outlines under Services and Benefits that Prosthetic
Appliances are covered when obtained from a participating provider. The
COC defines Prosthetic Appliances as "appliances which replace all or
part of an absent body organ (including contiguous tissue). Prosthetic
Appliances are also appliances which replace all or part of the function
of a permanently inoperative or malfunctioning body organ. Benefits are
provided for the initial purchase, fitting and necessary adjustments of
certain Medically Necessary prosthetic appliances."
I respectfully argue that a hearing aid, which replaces part of the
function of a malfunctioning body organ - the ear, clearly falls within
the definition of a prosthetic appliance as listed in the COC.
III. The COC does not specifically list hearing aids as an exclusion or
limitation. During our conversation, you indicated that hearing aids,
like eyeglasses, are not covered benefits. However, under Exclusions and
Limitations, Eye-related services, including eyeglasses and examinations
for them, are listed as non-covered benefits whereas hearing aids, and
examinations for them are NOT listed.
I respectfully argue that hearing aids and eyeglasses are not viewed by
the plan in the same manner or Ear-related services, including hearing
aids and examinations for them, would be listed under Exclusions and
Limitations.
When emphasis is placed in medical care on detecting major conditions
and then no further support is provided for their treatment, effective
care is compromised. Hearing aids are a medical necessity for the
hearing impaired; there is no pharmacologic treatment.
The situation for my son, and other children
with hearing impairment is critical, as their future productivity hinges
on gaining communication skills at a developmentally appropriate stage.
My son has benefited immensely from the use of
hearing aids. However, since his diagnosis at the age of 2,
his hearing loss has progressed from
mild-moderate to mild-profound (please see enclosed audiograms). Because
the majority of the clarity of speech is contained within the 1000 -
4000 Hz range, you can see, based on my son's
profound loss in this range, that his ability to perceive and comprehend
speech is greatly limited.
The hearing aids I am requesting authorization to purchase are the
newest technology and offer persons with profound hearing loss across
the higher speech frequencies an option that has not been available to
them previously. The AVR ImpaCt hearing aids are classified as
transposition aids; they work by transposing (compressing) the high
frequency sounds into lower frequency sounds where the individual
wearing them still has residual hearing. Our other
son has been wearing these hearing aids for a year now and his
expressive and receptive language skills, as well as his speech
intelligibility, have improved immensely.
In summary, I believe the plan has arbitrarily defined hearing aids as
"medical devices" when, in fact, they clearly fall within the definition
of prosthetic appliances as outlined in the COC. I respectfully ask for
the plan to consider providing coverage for these Medically Necessary
hearing appliances and look forward to your prompt response to this
request.
Sincerely, |
Re: Request for Formal Grievance Hearing Pursuant to
LSA Certificate of Coverage Complaint and Grievance Procedure
Dear Grievance Committee,
I am writing this letter to express my concern over the decision by my
health plan, UK-HMO, to deny coverage for the purchase of hearing
appliances (hearing aids) for my son.
I have had numerous contacts with plan representatives regarding this
matter since December 4, 2000. A written appeal was submitted to the
plan on December 7, 2000. The appeal was reviewed, and the decision of
denial of coverage for hearing aids was upheld in a letter dated
December 19, 2000. Pursuant to the complaint and grievance procedure
outlined on page 57 of the LSA Certificate of Coverage, please consider
this letter a request for a Formal Grievance Hearing.
As stated in my formal appeal to the plan, I believe the plan has
arbitrarily defined hearing aids as "medical devices" when, in fact,
they clearly fall within the definition of prosthetic appliances as
outlined in the Certificate of Coverage. I look forward to the
opportunity to discuss this issue with the Grievance Committee.
Sincerely, |
| Re: Formal Grievance Hearing Evidence for
Our Son Dear Grievance Committee:
In a letter to Ms. X, UK
HMO Utilization Manager, dated December 7, 2000, I carefully outlined my
reasons why I believe UK-HMO has arbitrarily defined a hearing aid as a
medical device and why I believe hearing aids are covered benefits as
outlined in the Certificate of Coverage. In a letter dated December 19,
2000, Dr. Y, UKHMO Medical Director, responded
indicating that my written appeal of the denial of coverage for hearing
aids had been upheld. Pursuant to the complaint and grievance procedure
outlined on page 57 of the Certificate of Coverage, I submitted a
request for a Formal Grievance Hearing on January 7, 2001. The hearing
has been scheduled for Friday, February 23, 2001 and I am writing this
letter to submit additional evidence supporting my appeal of UK HMO's
decision for denial of coverage for this important benefit.
As stated in my formal appeal to the plan, I believe
the plan has arbitrarily defined hearing aids as "medical devices" when,
in fact, they clearly fall within the definition of prosthetic
appliances as outlined in the Certificate of Coverage and repeated
below:
"Prosthetic appliances are appliances which
replace all or part of an absent body organ (including contiguous
tissue.) Prosthetic appliances are also appliances which replace all
or part of the function of a permanently inoperative or
malfunctioning body organ. Benefits are provided for the initial
purchase and necessary adjustments of certain Medically Necessary
prosthetic appliances.
I respectfully submit the following for your
consideration.
- The National Institute on Deafness and Other Communication
Disorders, provides a glossary of frequently used medical terms.
This glossary, accessed at
http://www.nidcd.nih.gov/health/glossary/glossary.asp
on January 5, 2001, defines an "Auditory Prosthesis" as a device
that substitutes for, or enhances the ability to hear.
I respectfully suggest that a hearing aid,
because it is a device that functions to enhance a person's ability
to hear, is clearly an auditory prosthesis as defined by the NIDCD.
- In an article published in the American Journal of Audiology,
Vol 7, November 1998, Robert G. Turner of Louisiana State University
Medical Center writes about the four categories of auditory
prostheses: hearing aids, assistive listening devices,
cochlear implants and surgically implantable aids - bone anchored or
middle ear implants. (article accessed at
http://www.asha.org/NR/rdonlyres/7FB469FA-C706-4C9E-A0D2-040A9AC9D1AD/0/3061_1.pdf)
I respectfully suggest that hearing aids are
commonly referred to by professionals as "auditory prostheses" as
evidenced by this article published in the journal of the American
Speech-Language- Hearing Association, the professional organization
of audiologists and speech pathologists.
- All textbooks of physiology refer to the ear as an "organ" and
the Certificate of Coverage defines a prosthetic appliance as an
appliance that replaces all or part of the function of a permanently
inoperative or malfunctioning body organ.
I respectfully suggest that a hearing aid, which
replaces part of the function of a malfunctioning body organ - the
ear - clearly falls within the definition of a prosthetic appliance
as outlined in the Certificate of coverage.
- The information sent from the plan in response to my written
appeal provided no reasons or data explaining why the plan has
classified hearing aids as "devices".
I respectfully suggest that defining a hearing
aid as a "device" really has no meaning. The FDA Medical Device
Regulations establish three regulatory classes for medical devices -
class I, Class II and Class III - that range in complexity from
enema kits and elastic bandages, to wheelchairs to implantable
pacemakers. I am certain that the plan provides coverage for many of
these medical devices as defined by the FDA and to deny coverage
based on the fact that something is a "device" is clearly arbitrary.
- I am aware that the plan has provided coverage for hearing aids
under certain circumstances, such as persons with hearing loss
induced by chemotherapy.
I respectfully suggest that it is not in the best
interest of the Plan's insured persons for the Plan to discriminate
in this manner. Is an insured person who lost their hearing due to
chemotherapy more deserving of adequate amplification than a child
who lost their hearing for reasons that are not known?
When properly fitted with hearing aids and provided
with appropriate rehabilitation, research shows that children can use
their residual hearing and develop speech and language skills that are
equivalent to their hearing peers. On the other hand, unmanaged hearing
loss in children can be devastating, leading to impaired speech and
language development, difficulties in communicating, academic failure,
low self-esteem and emotional and behavioral problems. Recent studies
have shown that even a child with only a mild – moderate hearing loss,
if left untreated, has a much higher likelihood of repeating a grade
than does a child with normal hearing.
For these reasons, I urge the Grievance Committee to
reconsider the Plan's denial of coverage for hearing aids and I look
forward to discussing this further at the formal grievance hearing.
Sincerely,
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Oral Remarks Prepared for Grievance Hearing 2/28/01
I am very grateful that I have been allowed to
address the Grievance Committee regarding my request for coverage for
hearing aids for my son. I have submitted much information to the plan
outlining why I believe hearing aids are covered benefits as outlined in
the certificate of coverage. You each have copies of these materials so
I am not going to restate that information. However, I would like to
provide some additional information for your consideration.
First, hearing aids are not a luxury. They are a
medical necessity. We are lucky that new technology has produced hearing
aids that provide high quality digital amplification and aids that can
provide benefit to persons with severe to profound hearing loss in ways
never thought possible. However, with technology comes a price. These
high quality aids often cost $2,000 to $2,500 each, and since most
persons with hearing impairment require two aids, the cost of providing
appropriate amplification can be significant. The set of hearing aids
that we are requesting coverage from the plan are the 5th set
of aids that our family has purchased between our two sons over the past
3 years yet this is the first time I have entered into grievance
proceedings with the plan.
Second, our health plan - UKHMO - is a health
maintenance organization….what does that mean "health maintenance
organization"…an organization providing health benefits with the purpose
of "maintaining health?" Numerous studies have documented the adverse
effects of untreated or improperly managed hearing impairment. While it
is common to think of academic failure as a consequence of untreated or
poorly managed hearing impairment, many other relevant health issues
should also be considered. For example, persons with hearing impairment
are at risk for depression, stress, anxiety, and chemical dependency.
Would it not make sense that a "health maintenance organization" would
want to provide means for the hearing impaired, through appropriate
amplification, to decrease their risk for the above conditions and
"maintain health" of their covered persons.
Third, my son has been
receiving speech therapy services as a covered benefit under the plan.
For the past 4 weeks, he has been wearing the hearing aids I am
requesting coverage for on a "trial basis". Our son's
speech therapist has reported to us that he is responding in therapy
much better with these aids. If the plan provides coverage for these
aids, then Edward will receive more benefit from the other services the
plan is already paying for!
Fourth, the plan does provide coverage for prosthetic
devices, as I have outlined in two previous letters. If
our son were unable to walk due to a birth
defect or physical impairment involving his leg, the plan would provide
coverage for an appropriate prosthetic device or brace to help him walk.
Why then does the plan believe that providing a hearing aid to a child
with the disability of hearing impairment is any different? Does a child
deserve to walk more than he/she deserves to hear?
Fifth, our family pays significant out-of- pocket
costs for health care services related to our two
son's hearing impairment. These out-of-pocket expenditures have
been occurring since they were first diagnosed at UK and subsequently
referred to the Lexington Hearing & Speech Center by the audiologists at
UK. This referral occurred because "LHSC has the most experience working
with kids". Obviously, as parents of a child newly diagnosed with a
disability, we wanted to make sure that they were receiving the best
care and follow-up available. Thus, we have incurred expenses associated
with quarterly audiologist visits, speech therapy and other related
services that have been paid for out-of-pocket. We believe we are doing
our part in providing the health care services our children need and are
asking that the plan do its part as well.
Thank you for your time and consideration. I am
hopeful that the grievance committee will come to the same determination
as I have - that hearing aids are a type of auditory prosthesis, and as
such, are covered benefits under the plan. |
Trish tells us: I wanted to send you these files from my
battle with my insurance company for coverage of my son's hearing aids. It took
a while (5 months), but I finally was successful and our son received his new
aids this past May.
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