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  1. #1
    Support Leader kadi's Avatar
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    Question BlueCross denial of PTNS treatments = $4,000 bill to dr office

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    Hello all,

    This spring I had a series of PTNS treatments. They were helping, but on the 10th treatment, I got a letter from Blue Cross requesting more information, and telling me my bill could be $360-$420 per treatment. My doctor's office became concerned about denial of coverage and sent them a full history of my condition, petitioning them for coverage, and immediately stopped the treatments before the end of the series, recommending that I not even have the one month follow-up maintenance treatment. I'm now worried I'll lose the benefit I had from the series by not doing the maintenance treatments.

    Today I received the official denial of all the PTNS treatments, potentially leaving me with a bill of about $4,000. My doctor's office had contacted BC for preauthorization and were told they would not do one because the treatments are covered under my plan. Now Blue Cross is claiming the treatments are "investigational" and will not cover any portion of them.

    Tonight I wrote a letter to my doctor asking for help with this, stating why I believe it should be covered and/or my bill lowered. I think I have a pretty good argument, as PTNS is mentioned in the AUA guidelines for IC treatment, and the AUA IC treatment algorithm. It's a fourth line treatment, and I have had every one of the treatments outlined in first-third lines. I also believe that it is inappropriate for me at the end of a 12 week series to be suddenly told "no coverage, so full payment", when I and the clinic made every attempt to obtain preauthorization, and the "Evidence of Coverage" book for my insurance plan never mentions neuromodulation as an excluded or limited form of treatment.

    Regarding the actual bill itself, I need to find out if the delay in processing occurred because the billing office took too long to file the claim or if BC delayed processing it.

    Anyone successfully appeal BC denial of PTNS? If so, what made BC change its mind?

    Very frustrated and a bit scared at the big bill,
    Kadi
    Kadi

    -------------------------------------------------------------
    I am not a medical authority nor do I offer medical advice. In all cases, I strongly encourage you to discuss your medical treatment with your personal medical care provider. Only they can, and should, give medical recommendations to you.
    ------------------------------------------------------


    New favorite quote: "God gives us only what we can handle. Apparently God thinks I'm a bad-ass" ~Author Unknown
    Source - Pinterest
    "


    Current treatments:
    -IC diet
    -Elavil 50mg at night
    -Continuous use birth control pills (4-5 periods/year)
    -Heparin/Marcaine/Sodium Bicarb home instills at night 3-4x per week, more often if needed
    -Pyridium if needed,
    -Pain medicine at bedtime daily, as needed during the day several times per week
    -Antibiotic when doing an instillation to prevent UTI
    -Colace & SmartFiber to treat chronic constipation from meds, Fleet enema as needed
    -Dye Free Benadryl 50 mg at bedtime
    -"Your Pace Yoga: Relieving Pelvic Pain" dvd, walking, treadmill at gym
    -Managing stress= VERY important!
    -Fur therapy: Hugging the cat!

  2. #2
    ICN Staff ICNDonna's Avatar
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    Mar 2000
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    Oregon
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    I'm so sorry --- nobody with IC needs added stress.


    Donna
    Have you checked the ICN Shop?
    http://www.icnsales.com for US & Canada
    http://www.icnshop.com for all others

    Patient Help: http://www.ic-network.com/patientlinks.html

    Sub-types https://www.ic-network.com/five-pote...markably-well/

    Diet list: https://www.ic-network.com/interstitial-cystitis-diet/

    AUA Guidelines: https://www.ic-network.com/aua-guide...tial-cystitis/




    I am not a medical authority nor do I offer medical advice. In all cases, I strongly encourage you to discuss your medical treatment with your personal medical care provider. Only they can, and should, give medical recommendations to you.
    [IMG]

    Anyone who says something is foolproof hasn't met a determined fool

  3. #3
    Support Leader kadi's Avatar
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    Dec 2003
    Location
    California
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    Good news

    Nurse called today to say that my urologist called the Blue Cross reviewer (dr) who denied my claim, and he was successful in appealing it. Blue Cross will cover the PTNS treatments after all.
    Since it will be 2 months since my last treatment before I can get in for a maintenance treatment, I hope it will still be useful....
    Very grateful to my urologist who took the additional steps!
    Kadi

    -------------------------------------------------------------
    I am not a medical authority nor do I offer medical advice. In all cases, I strongly encourage you to discuss your medical treatment with your personal medical care provider. Only they can, and should, give medical recommendations to you.
    ------------------------------------------------------


    New favorite quote: "God gives us only what we can handle. Apparently God thinks I'm a bad-ass" ~Author Unknown
    Source - Pinterest
    "


    Current treatments:
    -IC diet
    -Elavil 50mg at night
    -Continuous use birth control pills (4-5 periods/year)
    -Heparin/Marcaine/Sodium Bicarb home instills at night 3-4x per week, more often if needed
    -Pyridium if needed,
    -Pain medicine at bedtime daily, as needed during the day several times per week
    -Antibiotic when doing an instillation to prevent UTI
    -Colace & SmartFiber to treat chronic constipation from meds, Fleet enema as needed
    -Dye Free Benadryl 50 mg at bedtime
    -"Your Pace Yoga: Relieving Pelvic Pain" dvd, walking, treadmill at gym
    -Managing stress= VERY important!
    -Fur therapy: Hugging the cat!

  4. #4
    Support Leader Julie B's Avatar
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    Mar 2000
    Location
    Clarkston, Michigan
    Posts
    4,139
    That is excellent news, Kadi! Sorry I didn't see this before. XOXOX
    Julie Beyer, MA, RDN
    IC Dietitian, Patient Advocate, Speaker, & Author


    Did you know that up to 94% of interstitial cystitis patients find some symptom relief when they change their diet, and that dietary modification is recommended as a first line treatment for IC? Check out the IC Food List to get started!

    Do you need a little more help understanding the IC Diet? Schedule a phone or video coaching session through the ICN Store today.

    You can also learn more while supporting the ICN message boards by clicking on these book covers and buying the Confident Choices books from the ICN Store:

    ........ ........


    Other IC Diet Resources:

    IC Diet Webinar
    IC Diet Website
    For Health Professionals: Continuing Education About Interstitial Cystitis and Diet
    Free IC Diet Booklet: What Can I Eat?
    Confident Choices IC Diet Blog
    IC Diet Newsletter


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  5. #5
    ICN Staff ICNDonna's Avatar
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    Oregon
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    Quote Originally Posted by kadi View Post
    Nurse called today to say that my urologist called the Blue Cross reviewer (dr) who denied my claim, and he was successful in appealing it. Blue Cross will cover the PTNS treatments after all.
    Since it will be 2 months since my last treatment before I can get in for a maintenance treatment, I hope it will still be useful....
    Very grateful to my urologist who took the additional steps!
    I sometimes get really upset with insurance companies! It seems like every time I blink there's another denial, then my doctors file appeals and it's approved. I'm sure there are lots of people who don't appeal so it must save them money.

    GRRRRRRR

    I'm glad for you that you won't have to pay that bill.

    Huuuugs,
    Donna
    Have you checked the ICN Shop?
    http://www.icnsales.com for US & Canada
    http://www.icnshop.com for all others

    Patient Help: http://www.ic-network.com/patientlinks.html

    Sub-types https://www.ic-network.com/five-pote...markably-well/

    Diet list: https://www.ic-network.com/interstitial-cystitis-diet/

    AUA Guidelines: https://www.ic-network.com/aua-guide...tial-cystitis/




    I am not a medical authority nor do I offer medical advice. In all cases, I strongly encourage you to discuss your medical treatment with your personal medical care provider. Only they can, and should, give medical recommendations to you.
    [IMG]

    Anyone who says something is foolproof hasn't met a determined fool

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