NOT MEDICALLY NECESSARY per, by their own description, non-medical people

by Michael S. Kaplan, published on 2008/01/20 19:31 -05:00, original URI: http://blogs.msdn.com/b/michkap/archive/2008/01/20/7177837.aspx


Nothing technical here, sorry!

You may recall a couple of years back when I first mentioned the iBOT, the improvement over powered wheelchairs and scooters that lets you:

If you saw the post before the Viacom lawsuit took all those videos off of YouTube or the Colbert Report episode with the Dean Kamen interview, you'd even get to see Stephen drive it around a bit....

I recently went through the assessment for the iBOT, for a whole bunch of reasons involving lots of real world examples where the above four points translated into limitations that a scooter simply would not overcome. It really is (euphemistically speaking) the difference between walking with a limp and running a marathon in so many different circumstances that ah honest assessment changed it in my eyes from being a luxury to being a real necessity.

Anyway, Premera Blue Cross turned me down, claiming that it is

...not medically necessary. This system is a specialized mobility system with extra cost convenience features such as stair climbing ability and elevation ability which are excluded by contract....

If you decide to receive this service, you will have to pay for it yourself. Our decision is for payment purposes only. All decisions about actual treatment are between patients and their doctors.

The funny part is that there is no such information in any contract that I have access to (the actual information on assistive devices is intentionally vague and refuses to spell out the kind of details that would help a person understand what the criteria are), so I assume this must be something to do with either a contract between Blue Cross and Microsoft or between two different parts of Blue Cross.

I guess it is also a little funny that that they bat around phrases like not medically necessary even though they claim that All decisions about actual treatment are between patients and their doctors. If they are limiting themselves to payment then aren't they supposed to limit themselves to things like too expensive and such? Especially without a contract they hand patients that actually defines the criteria with any kind of certainty or rigor?

I have been told by several people who have dealt with Blue Cross (both inside and outside of Microsoft) that it is harder for an out-of-network provider to be considered to be providing medically necessary services, in addition to the fact that out-of-network pays 80% of the "reasonable costs" once they determine what is reasonable....

The appeal process will get a small workout and perhaps eventually I'll have an iBOT somewhere between the first and second appeals.

In a way it makes sense to me that as a company Blue Cross might choose to consider the iBOT to be not medically necessary, since me not having the iBOT protects them from having to look me in the eye when they deliver the news. This has the same logic as the issue I mentioned in Get off my freaking key! where the location of the @ sign some one of the layouts mske it more difficult for people to send mail to complain....

I'll keep you posted as I go through the process....

 

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# Skip on 20 Jan 2008 9:27 PM:

So it seems to me that making the determination as to whether or not something is medically necessary is by its very definition a medical question.   Was the person who made this determination a Doctor?   If not, I'd say he was practicing medicine without a license, and the attorney general might be interested.

Especially since this is an election year and going after insurance companies is always popular.

# Mihai on 21 Jan 2008 12:47 PM:

I can understand that such a device is more expensive.

And I can understand that they don't want to pay for it.

But the excuse is really lame. "Not medically necessary?"

And claiming that stair climbing is a "convenience" feature?

I wonder if they checked this with a layer first? Hope not :-)


referenced by

2012/06/21 Court stomps on NetFlix's disability argument (aka It Is The Best Of Times...)

2008/10/28 From I SCOOT to IBOT, #1 of ??

2008/10/23 Cogito ergo cathedra... (I think, therefore IBOT...)

2008/03/26 Cleaning up the water (globally) and hoping to get around better

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