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Has anyone experienced trouble from their insurance companies over getting the procedure approved? Does anyone know how insurance is likely to react to a surge of CCSVI angioplasties? I know there are billing codes, but they're not specifically for CCSVI: will this cause the insurance companies, once they catch on, to stop approving these claims?

I don't have the answer, but I am in the process and will be submitting those codes to my insurance. I'm not sure they'll pay -- they may reject it outright. It really depends on the insurance company as well. I have an HMO so I'm kind of sc*ewed as they are the worst.

If they were smart, they would pay for this procedure as they'll probably be paying out a lot less for MS drugs. I know people who are hoping to quit Tysabri, and that's $5,000 per mo per patient.

UHC covered 100% of mine a year ago.

Keep in mind it's probably more related to the details of the actual policy your employer has with the insurance company, than the insurance company itself.

I have also been wondering about all of this. What is the 'reason' for the tests and the angioplasty? I can't get an x-ray unless there is a 'cause' or 'reason' so what cause is being given to the insurance company to support the need of an MRV, Doppler or angioplasty?

There are ways of working it out with the codes. They can be specific or general depends on how it is sent in to the insurance company.

I'm expecting right now it is more a general code of vascular occulsion or something similiar. Swelling, headaches and any other symptom can be put down for Dx. So there is never a mention of MS or CCSVI.

Now as an influx of angioplasty procedures comes... well I don't know how they will react. I think it would take some time before a significant amount come through to be "detected". By that time, perhaps it willbe an "accepted" procedure.

And yes, it is SIGNIFICANTLY cheaper than drugs

Rieja wrote:Now as an influx of angioplasty procedures comes... well I don't know how they will react. I think it would take some time before a significant amount come through to be "detected".

This is what I'm wondering about. It's speculation, I know, to try and guess if insurance will start to push back on this. I've been preauthorized for the procedure, so I should personally be ok, I'm just wondering if there is a tipping point up ahead when we get the angst of insurance denials on top of all the other angst. Or maybe the trajectory is that this becomes more and more accepted and there never is that sort of 'push back' or rejections from insurance companies?

Rieja, you are right, it can be submitted for headaches or swelling and those symptoms, which many of us have as well, and then it'd be discriminatory to reject claims just because the person with the headaches and swelling has MS (hello, Canada...), wouldn't it?

I think the "tipping point" has been reached, at least in my case. BC/BS has just (moments ago) denied pre-approval for my head and neck MRV. They approved my chest MRV.

I had my angio abroad and my private health insurace paid for it. No fuss whatsoever, no code asked but note that I live in Europe.

CaptBoo wrote:I think the "tipping point" has been reached, at least in my case. BC/BS has just (moments ago) denied pre-approval for my head and neck MRV. They approved my chest MRV.

We've heard of an MRV denial before (the doctor appealed the next day and the MRV was granted, maybe this could happen still in your case? Sympathies, hope it works out). I asked Dr. Sclafani about it and he said the insurance company was right, that MRVs are not indicated for this, that it should be a transcranial ultrasound doppler. Still it makes me uneasy!

Haven't I read that Dr. Siskin in Albany has had good luck with getting insurance to cover? I thought he had it preauthorized in advance . Also, I thought medicare covered it accept for co-payments or deductibles. Anyone know?

i was fortunate that my ins. paid. so far so good. but if these ins. co.'s would start to deny what could they have to stand on? i'm sure that i'm not the only one who had symptomns like headache, purple hands and feet, numbness etc. these are all indications of blood flow problems. so, if they start to deny testing for circulatory problems because we have ms that is not a good enough answer. that to me would be no different or acceptable-what next?-are they gonna tell me that just because i have ms i can't possibly have anything else wrong. wouldn't that be nice if that was true. but, i do see where you guys are coming from and hopfully we won't have to deal with that too. i think the doctors dealing with this are working hard to get all this in order.

I'm waiting for my insurance approval. Wish me luck.
If things go well I'll be liberated by the end of September.

I had a few issues with my insurance company. They approved my Tysabri, approved my physical therapy, then turned it down. I called and explained to their reviewing doctor that I have Progr. MS, so I expect to get worse, etc..
He approved it. Then got turned down for Rituximab. Challenged the determination with the State insurance review board, and got approved.
You must challenge any denial. I have a friend that goes to small claims court where the cap is $5,000.00. It usually gets settled before the hearing. He's done this a few times. The insurance company must hire a lawyer, who as we all know, are all about billing. They have to prepare, use an associate, etc. It gets expensive.

nellie wrote:Haven't I read that Dr. Siskin in Albany has had good luck with getting insurance to cover? I thought he had it preauthorized in advance . Also, I thought medicare covered it accept for co-payments or deductibles. Anyone know?

Medicare covered my first procedure in their typical "slice and dice" manner: the hospital charge of $38,000 was reduced to $5,500.

I had only to cover the usual Medicare deductibles and annual copay.

Dr. Siskin gave me a lot of push back concerning the necessity of getting pre-approval from Medicare before he would preform the procedure on me. Later I found out that Medicare doesn't give out pre-approvals for anything and actually they have 90 days before they have to respond the the doctors and hospital's charges. Basically if a doctor accepts Medicare for any type of treatment, you're covered for CCSVI procedures.

Dr. Siskin basically didn't want to follow the previous work by other IR's so was trying to find excuses not to treat me.

Donnchadh

CaptBoo wrote:I think the "tipping point" has been reached, at least in my case. BC/BS has just (moments ago) denied pre-approval for my head and neck MRV. They approved my chest MRV.

Ugh. BCBS did mine (ppo though) no problems.

Thing is, it's easy to confuse your insurance company, with your insurance provider. My insurance provider, i.e. the people who cut the checks the hospital cashes, is IN the BCBS network/umbrella. My provider hasn't changed one tiny dollar in coverage from what they did before, when they were in the other network which you would not recognize, and which it was extremely difficult to find a good doctor. When they changed to BCBS, all the bills and interaction went directly to BCBS, they in turn had charts for what the trust fund covers and doesn't, and paid out accordingly. The actual dollar figure involved (per office visit, how much xrays, all that) hadn't changed, the amount of contractural providers though had exploded, which explains how someone like me in So Cal, working out of a trade union, can go to a hospital 500 miles away and be covered.

However I will say I spent quite a bit of time on the phone with them before ever departing for that expensive adventure. This is so people reaize they may be in the BCBS network, but what your specific insurance company pays or doesn't pay for is specific to that company and needs a lot of investigation beforehand. That's why I think the codes help to at least broach the subject with them first.

I'm assuming you are HMO due to the pre-approval? My codes for the MRI/MRV were 70549 neck+ 70553 brain, radiologist fees. The MRI only says 611 but that may be their internal numbers. Each MRI/MRV (head+neck) was 6207.00 charged, with a benefit amount of 2806.00 each. The rest is contractural writeoffs.

Not sure if that helps, wish everyone could just go in there and get it done without all the headaches.

Mark