"Experimental" Treatment

Frances,
I would talk with the doctor's office and ask them if it's FDA approved or if something changed. And if it is, how you can find some proof. They should be able to help you if the doc's doing the procedure. He/she should certainly know it if it's considered experimental for some reason.

Also - make sure an accurate procedure code was used when it was billed and authorized. There are constant changes in procedure codes, and insurances can also change what category they put a procedure into. But a lot of times I've found the wrong code was used, and that created the problem. Your doc's office should have had the procedure preauthorized - unless it wasn't required.

PaLady

Thanks, Tom.
I did check on the procedure code with my insurance company. I looked up the code & it was correct.

My doc's office wasn't terribly helpful. They just said they couldn't do any more & needed payment from me. I took care of it, but still it was a hundred some dollars that I really don't have. I know they get as aggravated and I do with all these stupid, ever-devolving rules that the insurance companies make up based on research which was probably done by some guy out of his van down by the river https://www.healingwell.com/community/emoticons/tongue.gif so I try not to press them too hard when it comes to insurance rules.

Normally my doc's pretty cool about these things & if he knows it's gonna be denied he comps it, so I was kinda surprised when I found out it wasn't covered. My insurer randomly changes the number of facet injections allowed at an office visit, regardless of the medical necessity. My doctor thinks that's bad practice, so he keeps giving me the same number of shots & only bills me for the number I'm "allowed" to get covered at the time. Usually that amounts to a few hundred up to a few thousand dollars per visit. Because of that, I don't want to "rock the boat" with him too much, but if I can get this covered on my own all the better.

Let me know if you have any better luck getting yours paid for. Sometimes I've been able to "trick" the evil insurance gremlins https://www.healingwell.com/community/emoticons/devil.gif into covering something by referencing other companies who cover it.

hee. hee. hee. (jk, I don't really have an evil laugh like that) :)

Frances,
Tspauld actually put more clarity on what I was trying to say earlier. You actually may have more than one code for the same procedure, and sometimes it gets messed up between doc's office and insurance. Or the insurance changes and they're only covering one of the procedure codes when they used to cover two or three. This happens all the time. And docs office may not catch it.

Also remember procedure codes are different from billing codes - as if one wasn't enough! Sometimes I've been able to figure this out and get the codes myself, but only after a lot of time spent on the phone with doc and insurance company. Usually, though, the doc's office has to supply the procedure code. And if something changed recently with insurance it may not be in doc's office computers yet.

Then again, it just might be something with the FDA. The fun never ends!

Good luck!

PaLady