Finally, a glitch, though mercifully it’s bureaucratic and not medical.
When we first scheduled the surgery, I’d been worried about bureaucratic problems, because the surgery was scheduled for early January, and we had switched our coverage from Oxford Health Plans to Empire Blue Cross Blue Shield, effective January 1. I was certain that the necessary pre-approvals wouldn’t be processed in time. But lo and behold! My Empire ID card arrived before my final appointment with Dr. Feldman, and all the paperwork went through smoothly. The hospital visit, as I wrote before, was a breeze.
But then today I checked the claims section of my Empire account online.
I saw that Dr. Matthews’s claim had been processed and paid and that Dr. Feldman’s claim for the surgery was in process. The claim that I submitted for the EBIce Cold Therapy unit, however, had been denied.
The note on the Explanation of Benefits statement reads as follows:
We do not have sufficient information to determine the clinical appropriateness of the services reported on this claim and are therefore denying the services. You must submit supporting documentation, including peer group literature, which would suggest that these services are clinically appropriate for a person with the reported condition in order for us to reconsider the claim.
I find that amusing. It would be one thing if Empire had responded that durable medical equipment was not covered by my policy. But to question the appropriateness of cold therapy in the aftermath of serious knee surgery?
I am of course planning to appeal. I’ve already begun gathering what seem like appropriate pieces of supporting documentation, but I’ll consult with the doctor’s office when I visit on Tuesday to see what I should be submitting.
More on this as it develops.
good luck