Insurance Denied Doctor's Prescription

paininthe · #1 03-16-2007, 05:37 PM

I am in California. My 2 doctors and my physical therapist have all precribed a tens unit for my shoulder. The insurance company has denied the claim. the tens unit is the only thing that has made a real difference in the pain for me. Can the insurance company do that? What can I do?

jk · #2 03-16-2007, 07:29 PM

without knowing what your insurance covers, it is impossible to tell. Is it possible you insurance does not cover medical appliances?

paininthe · #3 03-16-2007, 08:08 PM

I don't know what the insurance covers. It's Travelers workers comp insurance co. Insurance nurse said they follow the guide lines according to a supposed third party physicians advisor.I have been off work and on workers comp since December.

aaron · #4 03-16-2007, 09:45 PM

Whether they're right or wrong, a worker's comensation insurer may attempt to argue that the treatment isn't medically necessary, or that the treatment is for a problem that is not work-related and thus not covered by worker's compensation. Sometimes it becomes necessary to get help from a workers comp lawyer.

What reason did they give for their denial of your claim? That their "third party physicians advisor" says it's not medically necessary, or not medically appropriate?

paininthe · #5 03-16-2007, 11:34 PM

She wouldn't tell me when I asked. She said a denial letter was sent to my doctor explaining why and I would have to get in touch with him. I again said to her , "so you can't just tell me the reason?" She acted like she was pretty annoyed with me asking and said "well I could read the letter but it is very long" I asked if she could just cut to the chase and tell me the reason? She replied saying for me to make an appointment with my doctor to find out, or he could file an appeal.

jk · #6 03-17-2007, 03:49 AM

so call the doc and ask them. You wouldn;t need an appointment for that, at least I wouldn;t think so. At my dr.'s office that is something I could even do via telephone.

when you first posted yesterday, at least by the time post on my computer, your dr.'s office was probably still open. It would have seemed prudent to at least attempting to call them.

paininthe · #7 03-17-2007, 02:54 PM

Thanks for your reply JK. I did call my doctor. He was in surgery , they said they would look up the info and call me back , but probably not untill Monday as it was already pretty late in the day on a Friday and doctor had been very busy all day in surgeries.

paininthe · #8 03-19-2007, 12:08 PM

Just recieved a call from my doctors office. They said they have no record of any letter of denial from the insurance co. My doctors office is now following thru with calls to the insurance co. to find out what is going on. My doctors office was frustrated with the insurance co. and said "they could have told you the reason why it was denied , and they always deny everything because it's workers comp and lie about everything too!"

lealea1005 · #9 03-19-2007, 12:24 PM

Quoting paininthe

Just recieved a call from my doctors office. They said they have no record of any letter of denial from the insurance co. My doctors office is now following thru with calls to the insurance co. to find out what is going on. My doctors office was frustrated with the insurance co. and said "they could have told you the reason why it was denied , and they always deny everything because it's workers comp and lie about everything too!"

A TENS unit may be considered Durable Medical Equipment (DME), and therefore, covered diferently than a regular prescription for medication or diagnostic testing. Your Physician may also have to write a letter indicating medical need for the device. Even then, there's still a good chance it'll be denied. Good luck.

paininthe · #10 03-23-2007, 01:04 PM

My doctors office has filed an appeal. In the meantime I was cc: a letter from insurance to my doctor saying that the physians advisor {not an M.D.}, had denied the claim and that he spoke with my doctor and my doctor agreed that my case didn't warrant the use of a tens unit. I Called my doctor to ask about that statement.My doctor said he never told the advisor that at all. Doctor said they twisted conversation to fit their purpose! I am going to see my doctor next week to see if there might be something else we could do because we will be going round and round with the insurance company for ever. I have a feeling we might be discussing cortisone shots. Any feedback on this run around or the shots?
Thank You!