Insurance Claim

[FedUpWith Insurance]

Hello to you all,

I have a son who is 16 and has just started eating food again after being on a Modulen diet for 8 weeks. My son decided to drink the 8 weeks of Modulen instead of being tube fed, and we are very proud of him for doing this. He has gained 15 pounds back so far and continues to do well with no pain!

My question here is, has anyone had a hard time with insurance claims for nutritional supplements? Although my son was brave enough to drink 7 shakes of Modulen a day for 8 weeks, our Insurance company is denying our claim because he wasn't tube fed.

I would be interested in hearing other stories of Insurance Claims being denied, and if you won in the end.

 

[SupportiveMom]

I was told the only way insurance would pay for it was if it was tube fed. That was part of our decision of why we went NG (though my kid wouldn't have stuck with it. Goo d job for your son!) I'm tagging Tesscom who had her son on modulen or peptamin and it was drank orally. She is also in Ontario so it may help.

Glad your son is heading in the right direction!

 

[Tesscorm]

S had his feeding by ng tube but, regardless, it was not covered at all by our insurance company. Our insurance company classified it as a nutritional supplement not a drug, thus was not covered.

However, at diagnosis, while he was inpatient, the hospital put us in touch with CCAC and they covered the cost of the formula, tubes, bags, rental of equipment, etc. for as long as it was prescribed by his GI.

We were also told if CCAC did not cover the cost entirely (because I believe the final decision lies with individual branches of CCAC??), Ontario also has the Trillium (I think that's what it's called) drug coverage - a provincial drug program. I'm going to page DJW (I think???) - I believe he has some info re this drug plan shown in his signature.

And congratulations on your son getting through 8 weeks of EEN - certainly not an easy treatment! If your son has done well so far on it, I encourage you to keep on it as a supplement. After my son's six week exclusive period, he added back a regular diet but continued with the formula as a supplement for two years (at half dose, so in his case, 1/2 dose was 1500 cal per day). He did very well with this; with no other meds, it kept his symptoms controlled for almost two years. (We did eventually add remicade as there continued to be simmering inflammation even though he had no symptoms. He now drinks 1-2 Boost shakes daily to maintain nutritional levels.)

 

[Jmrogers4]

My son did 8 weeks of oral peptide, insurance covered after we met or deductible. It was classified as failure to thrive the first time and because he was getting 90% of his nutritional needs through formula insurance covered. He did another 8 weeks about 8-9 months later again he drank it and it was covered since it was supplying 100% of nutritional needs. It took a lot to get it covered the first time. I had to call insurance, his gi office called and even the medical supply place called. They have me the same if it wad through a tube it would be covered, I said he is having it for all the same reasons it would be covered under tube feeding and kept asking to speak to someone else. Finally spoke to someone who when I said it was supplying all his nutrition she said they could cover. Good luck.

 

[my little penguin]

Same here DS drank it all orally.
He was labeled FTT prior to crohn's dx.
For him since doc had prescribed the cheaper stuff first ( boost kids )
And he still lost weight- insurance company just covered the peptamen jr.
He drank it as EEN for 9 weeks and has had 1-2 a day for the past three years .

 

[DJW]

Hi.

The link to the Trillium Drug Plan in my signature. I got my application from Shoppers Drug Mart. They will want to know about your primary insurance and household income.

 

[CrohnsKidMom]

Sorry to hear of your insurance frustration, but glad that your son is doing so much better. Just a couple thoughts... each insurance co. is different as far as how flexible they are, but it is the industry's standard that formula is considered more a food and less a drug. Every ins. policy is different too depending on what your employer is willing to pay for (if it's a group plan), or what you are paying for (if it's an individual policy). That said, a detailed letter from your GI explaining the necessity of the formula, and that it is being used as a treatment and not to supplement his diet, may help. If the pharmacy can show in writing that the cost of the formula is equal to, or less than the cost of steroid drugs, it may also help. Good luck!

 

[my little penguin]

Steriods are pennies per pill and formula is $1000/ month or more .
Which is why most won't cover it

 

[CrohnsKidMom]

Well, scratch the last part of my previous post then... But still, a letter from the GI explaining that this is a treatment may help. Keep us posted!

 

[FedUpWith Insurance]

Thank you to everyone for your support, kind words and advise!

Has anyone fought for their right in receiving their claim, or thought about appealing their Insurance companies decision?

 

[Cupkatemom]

We don't use modulen, and we are in the US...but we just used a Healthcare Advocate to fight our insurance company. We've resolved 3/4 and expect the last one to be resolved soon. Also...use twitter to tweet the insurance company (we got help that way as well). Best of luck!

 

[SupportiveMom]

Sorry Tess I misquoted S's Treatment!

 

[Tesscorm]

No worries! Sadly, too many to keep track of!