Insurance coverage

[Dearie]

Hello to all,

It's been a while since I posted anything. My son is doing well & currently experiencing no symptoms.

He has been taking supplemental EN (3 cans a day of Pediasure Peptide) along with the Pentasa, probiotics, omega-3, & Prilosec. But our insurance won't cover any of the cost of the pediasure peptide unless it's his only source of nutrition.

Has anyone had experience with sending appeals to get insurance to cover supplemental formulas?

Thanks for any advice,

~Dearie

 

[my little penguin]

You need to have it sent through a durable medical equipment (Dme) place.
The doc writes a script for it and a letter of medical necessity.
Most insurance deny EN but cover x% of home infusion supplies ( aka formula ) through the policy Dme clause.

Good luck

 

[Sascot]

No idea about the insurance, but that's great your son is doing well!

 

[Dearie]

You need to have it sent through a durable medical equipment (Dme) place.
The doc writes a script for it and a letter of medical necessity.
Most insurance deny EN but cover x% of home infusion supplies ( aka formula ) through the policy Dme clause.


Is a durable medical equipment place the same as home health because our doc wrote a script that I submitted to a home health agency and they informed me that my insurance will not cover the script? Thanks!

 

[munchkins]

Hello to all,

It's been a while since I posted anything. My son is doing well & currently experiencing no symptoms.

He has been taking supplemental EN (3 cans a day of Pediasure Peptide) along with the Pentasa, probiotics, omega-3, & Prilosec. But our insurance won't cover any of the cost of the pediasure peptide unless it's his only source of nutrition.

Has anyone had experience with sending appeals to get insurance to cover supplemental formulas?

I've no idea about sending appeals to get insurance coverage regarding your situation but you can try sending one or asking your insurance agent regarding that. Glad to have heard that your son is doing okay and we're hoping for his fast recovery.

 

[Patricia56]

You need to check your evidence of coverage booklet and see what it says.

Most HMO and PPO policies will only cover exclusive enteral nutrition.You can lie about it (with doctors cooperation) but that's the deal.

Some insurance plans - usually ones that let you see any doctor and you pay annual deductible and per visit deductibles - will cover it as home infusion but it's not typical as far as I've seen.

That's not to say you can't appeal it. But you will need to have an actual denial letter from the insurance in order to file an appeal.

So you will have to take the scrip back to the DME company and tell them you need them to submit it so you can appeal the denial.

 

[Dearie]

Thanks everyone

I already received the appeal form from my insurance company. I just need to fill it out, they said, and send it back along with any information I feel may be pertinent to their making a decision.
We have a doctor's appointment tomorrow and I will discuss it with her also.