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Sample Letters of Justification

 

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.

    1. 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.

    2. 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.

    3. 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.

    4. 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.

    5. I am aware that the plan has provided coverage for hearing aids under certain circumstances, such as persons with hearing loss induced by chemotherapy.
    6. 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,

     

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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