Challenging the insurance company for medical equipment is often frustrating, but persistence pays off.
On April 19, 2016, I wrote an article for CURE regarding my frustration over being denied the right to specific medical equipment ordered by my oncologist to treat a severe case of lymphedema. The insurance company, one of the larger, more familiar ones, determined the recirculating compression pump was “medically unnecessary.” They did not think it was needed to treat the swelling in my upper extremities and chest, so they refused to allow it and denied my claim. After contacting my doctor and apprising him of the situation, he agreed to send in medical documentation to substantiate his original order for the equipment. After months of sending medical records and having my doctor, physical therapist and the representative of the company that manufactures the compression pump collaborate on my behalf, I finally received word the insurance company had made a decision. A few days later, the written decision arrived. I was dumbfounded as I read the letter.
The insurance company stated once again that my claim for the recirculating compression pump had been denied. It was determined, that I had “not used a regular compression pump for three months before requesting the recirculating pump.” They did not feel I had given a regular pump a chance, and since I had not done this, my claim was denied. I was livid. How could I give a regular compression pump a chance when I’d never been given the opportunity to have one? If my doctor felt a regular compression pump would help me, wouldn’t he have ordered it in the first place? The reason he’d chosen the recirculating pump was because it was the best option available. With my lymphedema being centralized in my upper arms and the area beside my armpits along my chest wall, a regular compression pump wouldn’t even come close to touching those areas.
I crumpled the denial letter and threw it in the trash can as my face began to turn a bright shade of red and I could feel my blood pressure rising. I immediately got on the phone and called my doctor’s office, letting them know the insurance company’ decision. The nurse informed me she’d just read their copy of the letter. I asked what I should do and she said, “Don’t worry, we’ll submit more information and get this thing approved, but it may take some time.” She told me I might have to use a regular pump until they could get the funds for the recirculating pump approved, but it would happen. I felt better after speaking with her because I trust my doctor and his medical staff.
A few days later, I received a call from the company that manufactures the compression pumps. The representative told me they’d gotten approval from the insurance company to send me the regular pump. They wanted to set up a time for one of their sales people to come out and take measurements of my arms. It had been many months since the initial measurements were taken, and they were sure there had been some change. After agreeing to a day and time for the new measurements to be taken, my frustration grew.
The following week, a representative came to my home. She brought one of the regular compression pumps with her. After taking my measurements, she proceeded to give me a demonstration of this smaller, eight-chambered pump. She explained the recirculating pump was much stronger and its 15 chambers would be more effective at reducing the swelling from my lymphedema. She also explained the eight-chambered pump would only address my arms. It would not be able to reduce swelling in my chest. The recirculating model was equipped to overlap the chest wall and reduce swelling there as well as in the upper arms. That was the reason my oncologist had chosen that model in the first place.
I asked why I was being forced to use the eight-chambered model when it wasn’t going to do what my doctor prescribed. She explained this was pretty much standard procedure for the insurance companies. They wanted me to use the small pump for at least three months and document its effectiveness before proceeding to submit a claim for the larger, more powerful recirculating pump. The puzzlement on my face prompted the sales rep to reassure me by saying, “Don’t worry. Use this pump for a month or two and take measurements daily. Keep a strict record and when you don’t see any change for the better, contact your doctor and let him know.” I told her I knew I wouldn’t see a change for the better because the lymphedema wasn’t limited to my arms. If it had just been in my arms, this eight-chambered pump would have been just fine.
So, I’m following the rules. I’m using the eight-chambered non-recirculating pump for the next three months, and I’ll keep measurements daily. After those three months have passed, I’ll contact my doctor again and let him know I’m still not getting relief from the constant swelling pressure of my lymphedema. Hopefully, before the end of the year, I’ll be able to have the insurance company approve the equipment that was ordered for me initially. They did say that after the first denial I had a right to appeal. Well, by golly, I’ve appealed twice and I’m going to keep on appealing until I get the equipment I so desperately need. I have a good mind to take photographs of my ugly, swollen, fat arms and send them to the insurance company. Maybe if they saw physical evidence of the pain I go through daily, they might be more apt to approve the recirculating pump quickly, but I don’t think it would do much good. I think they have their rules and guidelines and they don’t care one bit about the welfare of their clients. I think it’s all about the money. It doesn’t matter if we pay our premiums religiously and on time every month. The smaller, eight-chambered pump is much less expensive than the 15-chambered recirculating pump, and that’s the bottom line. I’m not giving up! I’m going to keep on fighting. And sooner or later, I’m going to win. I’m not fighting for the principal of winning. I’m fighting for relief from a painful situation.