EN Update

LJS · Mar 30, 2013

Well, it's been nearly a month, and still no further.. my crappy insurance denied the EN therapy... it's taken all this time, but finally got approval for the equipment. BUT, the biggest expense, the formula (Peptamen JR) has been denied... my home health company is donating one month supply but not sure after that what I'm going to do.. I cannot afford the $1000+/month.. and in the meantime, while son was feeling pretty good most of the time, he started having fever/stomach ache/fever a few days ago... so very frustrating! I hate insurance companies..

CarolinAlaska · Mar 30, 2013

I'd take that as a sign to get started, then look at what resources the community may have to help with the formula. Our community has an organization called "Love, Inc" that would give some to help cover it, etc. You can also check with your local community services (your doc should know) organization that helps with people with disabilities to see if your child meets criteria for a medicaid program for kids with disabilities/disabling diseases. Whereas we don't qualify for medicaid in Alaska for income level, there is another program for kids with disabilities that she qualifies for. Originally it was for her seizures and cognitive delays that produced, now we're looking to see if it will cover her for her Crohn's. That medicaid has been a Godsend! It covers everything my regular insurance won't.

PS I hope your son starts feeling better soon.

Tesscorm · Mar 31, 2013

Yes, agree with Carol that you should keep looking... our insurance also denied the formula for my son, a regional agency agreed to pay for the initial six week exclusive period and would then review the need... It will be two years in May and they still cover the cost of the formula, even though it is no long 'exclusive'. It was our hospital that put us in touch with this regional agency.

my little penguin · Mar 31, 2013

also try through your durable medical equipment clause since most insurances do not cover EN formula out right but do cover infusion medical supplies (aka formula)

izzi'smom · Mar 31, 2013

Can you appeal? Izz has been denied multiple treatments initially but we appeal every denial and most of the time we aren't denied the second/third time around.

Jmrogers4 · Mar 31, 2013

Agree with Izzi's mom about an appeal. Is GI talking to insurance as well? This helped in our case. The DME company also talked to insurance, it was after the DME talked to them that we got formula approved apparently they gave them the right codes.

LJS · Mar 31, 2013

thanks.. everyone has spoken with insurance.. they also refused the supplies initially but after that appeal, they are covering. Just wont' cover formula.

my little penguin · Mar 31, 2013

If they are covering supplies you may have a case
Since formula is just infusion supplies .
Good luck

LJS · Mar 31, 2013

thanks.. any suggestions on who to talk to???

my little penguin · Mar 31, 2013

Do you have a case manager from the insurance company?
Ask for one.
Is the durable medical equipment company supplying the formula?
If not that is how most are covered.
Letter of medical necessity is needed .

LJS · Mar 31, 2013

My docs from Childrens' have been doing most of the work. I've had many conversations iwth the DME company, and they have told me they NEVER see formula get approved but they were pretty sure the appeal would go through for the pump, tubes, etc.. - which it just did, after 3 weeks. Have letter of necessity, case studies, etc.. it's all very frustrating. As a single mom, I cannot afford the costs involved..