Turned Down By Insurance? How to Write a Strong Appeal for Cochlear Implants

I’ve written quite a bit about how to appeal to your insurance for a cochlear implant -upgrade- new processor, but what if the insurance company turns you down before you even get out of the gate?  How can CI candidates appeal when insurance denies your request for CI surgery?


 

 

PLAN A

First, you’ll want to check out my guide to cochlear implant candidacy and undergo all of the necessary testing.  If your initial request is rejected, your first course of action is simply to resubmit all of the original paperwork as an appeal with letters of support from your surgeon, audiologist, and/or auditory-verbal therapist, stating why a cochlear implant is “medically necessary” for you.  Sadly, I’ve found, some insurance companies issue an almost blanket denial of CI surgery claims for all patients (even those who are clear-cut candidates), just to see if they can get away with it, I guess.  So, resubmitting all of the original paperwork with letters in support may help.

 

What makes a good support letter from a professional?  It should include the patient’s identifying information (name, DOB), diagnosis, and the length of time for which the patient has been in this clinician’s care.  Then, the doctor, audiologist, or therapist should detail the impact of the patient’s diagnosis on their functioning and use the magic words “medically necessary” to describe the need for the implant(s).

 

If that doesn’t work, it’s time for Plan B…

 

 

PLAN B

 

If the “send it back and hope it works” approach doesn’t stick, you need more evidence to support your case!

  • Learn about borderline cochlear implant candidacy.  Some people who do not fall under the traditional FDA guidelines for cochlear implantation are showing great results with the device.  Remember that “guidelines” are just that — guidelines.  They are not the law and, with your surgeon’s approval, it is possible to receive a CI (or two!) even if you’re not the traditional candidate.

 

  • Double-check your speech perception testing.  If you were tested at 60dbHL or higher, it might be worthwhile to redothe testing at 50dBHL, which is much closer to actual conversational speech levels.  Also consider having testing done in noise.  Speech perception testing at 50dBHL with multitalker babble (background noise that sounds like human speech in a crowd) is a much more realistic task.  You can make a good case that your low scores on speech-in-noise tasks represent your everyday functioning much more accurately than your hearing thresholds alone or your speech perception abilities in quiet.

 

  • Consider the accessibility of speech sounds.  What is your aided benefit?  Insist on aided threshold testing to see if your hearing aids are really boosting your hearing into that “speech greenbean” range needed to have full access to speech sounds. Most likely, they’re not.  Or at least not in all speech sound frequencies.  This can have a big effect on articulation development in children and on auditory comprehension for people of all ages.  Use this as evidence to support the need for a cochlear implant.

 

  • Consider your activities of daily living.  How does hearing loss affect your everyday functioning?  Is it a safety concern?  Are you able to hear on the telephone?  Has hearing loss affected your employment or your/your child’s ability to learn in school?

 

  • Consider rate of progress.  If a child is receiving good listening and spoken language therapy services, has good parent carry-over at home, and is still not making the expected rate of progress with hearing aids, this may be the key to your argument for a cochlear implant.

 

  • Contact the CI manufacturer.  Each CI manufacturer has a dedicated patient support/customer service team with lots of experience negotiating with insurance.  Let them know your situation and see if they can help move the process along.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s