orthopedic inserts

[cmdh]

OK the insurance co told me they only pay for ONE pair of orthopedic inserts for difficult child's feet...in her lifetime.... hello she is 4YO and still growing. The pediatrician thought they MIGHT last 6 months. :Hot Head:

Silly me wanted two pairs. After talking with the ortho that was fitting her she will probably need one pair for outside shoes and another for slippers etc in the house. She is to wear them as much as possible.

The ortho that fit her said he would do a letter of necessity for 2 pair.

Any experience with working with insurance co's on this. They told me we would have to submit next time she needs them and see if they will reimburse.

for gosh sakes..

 

[SRL]

Why is he suggesting two pairs of inserts? I have one pair of inserts that I put in a comfortable pair of good quality shoes (usually a walking or hiking shoe). Typically I put them on first thing in the morning and take them off when I go to bed at night.

If they are the sort of insert that is not affixed permanently to the shoe you should be able to remove them and put them into the slipper. It only takes a minute to make the changeover (at least in my case)-- not so inconvenient as to justify a second pair of very expensive orthodics.

 

[cmdh]

he wants to specially mold one pair for her street shoes and the other for slippers that are required at school and will be worn in the house. The second pair will double for sports shoes (soccer, ballet etc) because the fit of those shoes are all similar to the slippers.

After looking at her different shoes it makes sense to me. The form of each 'type' of shoe is different.

Now to see how much and or if the insurance will cover. I'm not holding my breath. Possibly we will start with one pair and when we go back for the evaluation discuss further if the one pair is correcting the issue or hurting it in the slippers/sports shoes.

 

[bigblueagain]

when I worked medical insurance precertification, most shoe inserts were not covered at all unless they are considered an extension of a brace, prosthetic, etc. That is because they are not always a "medical necessity" in that they are more a comfort measure that can be bought over the counter( ex" Scholl's etc). Now don't get all over me. But that is the way most old policies were written. You should call your insurance CS and ask what your benefit appeals process is. This is because you are not really looking at a medical necessity appeal, but a limited benefit appeal. I would ask them to ahve a like physician review your appeal however.( another orthopedist who has no financial gain from the insurer).BLUE

 

[cmdh]

thank you so much. I will have the dr do the letter of medical necissity for the 2 pair then fight the insurance co. At least I know what area to 'fight' now.

 

[GoingNorth]

Orthotics can also fall under the heading of 'durable' medical goods, same as crutches, walkers, etc., which a lot of policies won't touch.

The trick in our case with the orthotic husband required in his right shoe to manage a deformed foot due to a severe fracture, was this: putting it as a 'walking' issue, e.g. that he needed it in order to be able to walk comfortably didn't fly. What did fly were letters showing that insurable conditions: spinal arthritis and a deteriorating hip joint, were made worse by walking without the orthotic.

Basically you need docs writing letters on this. They have to show the ins. co., that paying for the orthotics is a lot cheaper in the long run than paying for ongoing treatment of conditions worsened by not using the orthotics.

I am not an insurance professional, but I am a combat-hardened veteran of years of trench warfare with ins. companies.

And yes...different types of shoes can require different orthotics. I can tell you certainly that the orthotic husband wore in his combat boot did not work in street shoes or vice versa.

 

[GoingNorth]

Orthotics can also fall under the heading of 'durable' medical goods, same as crutches, walkers, etc., which a lot of policies won't touch.

The trick in our case with the orthotic husband required in his right shoe to manage a deformed foot due to a severe fracture, was this: putting it as a 'walking' issue, e.g. that he needed it in order to be able to walk comfortably didn't fly. What did fly were letters showing that insurable conditions: spinal arthritis and a deteriorating hip joint, were made worse by walking without the orthotic.

Basically you need docs writing letters on this. They have to show the ins. co., that paying for the orthotics is a lot cheaper in the long run than paying for ongoing treatment of conditions worsened by not using the orthotics.

I am not an insurance professional, but I am a combat-hardened veteran of years of trench warfare with ins. companies.

And yes...different types of shoes can require different orthotics. I can tell you certainly that the orthotic husband wore in his combat boot did not work in street shoes or vice versa.