Problems Related to Health Insurance Coverage for Durable Medical Equipment

Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 19

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In some cases, claims for durable medical equipment -- braces, crutches, wheelchairs -- that should be covered by an insurance policy may be denied simply because they are not yet on the insurance company's list of "medically necessary equipment." In such cases, the Explanation of Benefits Statement may include a note that the equipment is not a covered expense or is not medically necessary.

For example, when I first began to use a power wheelchair, I anticipated that I might have some difficulty obtaining reimbursement from my insurance company. Power wheelchairs, after all, are quite expensive. My first power wheelchair cost more than $6,000. However, the claim was approved without any problem. A year and a half later, I bought new batteries for the chair. I filed a claim, and I attached a copy of the bill and a letter from my doctor explaining the need for the batteries.

Although the batteries were only $200, both the claim and the initial claim appeal I filed were rejected with the explanation that the batteries were not medically necessary and did not represent a covered expense. After several telephone calls to a supervisor at my insurance company, I discovered the problem: power wheelchairs were on the insurance company's list of medically necessary equipment, but wheelchair batteries were not.

I wrote a letter to the insurer, asking that the company review the question of whether wheelchair batteries should be added to the company's list of medically necessary equipment. I waited a month and filed another claim appeal. A few weeks later, I received a check from the insurer for the cost of the batteries.

If a claim for medical equipment is denied, talk with an insurance company representative to determine whether the equipment is on the insurer's list of medically necessary items. If it is not on that list, and you think it should be covered by the policy, write and ask the company to consider adding it. Then, wait a few weeks and file a claim appeal.

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