• johnna's Avatar

    johnna asked a questionEsophagus (Esophageal) Cancer

    Tube Feed Formula Insurance Coverage

    6 answers
    • BuckeyeShelby's Avatar
      BuckeyeShelby

      Hi Johnna. I work in the field of medical insurance. A good number of our groups do cover formula. Always remember, if you get a denial, you have the right to appeal the decision. You'll likely need to get documentation from your provider explaining why it is medically necessary. And you'll need to call your insurance company and ask them the procedure for filing an appeal. If the CSR on the phone gets nasty w/you, ask for a supervisor. They shouldn't be mean to you, as the phone rep has no vested interest in whether your appeal succeeds -- customer service doesn't make the decision. I wish you the best of luck in obtaining coverage for the nutrional needs.

      over 3 years ago
    • johnna's Avatar
      johnna

      Thanks all!

      We have Anthem BCBS and have appealed to the highest level of appeal thus far including the Independent review board. My husband's doctors have provided all of the documentation that he is solely relying on the enteral formula for nutrition. The most recent denial stands apparently and the final word of the most recent letter states, "We are the final authority in this decision." Nice, huh?

      The Cleveland Clinic Home Care supplies and delivers the formula and supplies without problem and the supplies and pump are covered under Anthem. But the actual Isosource 1.5 formula is not paid for. I have contacted the hospital social workers, dietician on is case as well as directly to the maker, Nestle. No one has any resources to help us. The Cleveland Clinic says they have yet to see anyone get the formula paid for by an insurance company. We don't qualify for public assistance, poverty level help according to Nestle and they said most of their assistance programs are targeted to families with babies on tube feeds, not adults. The cost of just his formula exceeds what i spent on our entire family's groceries per month. It's so frustrating!

      I can't even get an answer as to if the problem is the coding of it all during the billing process or not. And if so, what codes would be covered. The only explanation I get is that our plan does not cover the formula no matter how medically necessary. WTH!

      It apparently can be purchased online therefore making it an over the counter classification. Even though he is under the direct supervision of a home care nurse, dietician and oncologists. At least now they don't dispute the medical necessity as they used as the excuse in the first 2 appeals. Appreciate the feedback from you all. Thanks!

      over 3 years ago
    • mmoorewia's Avatar
      mmoorewia

      Our health insurance covers it 100% - this is after our "out of pocket" was met - but that was met early on. With a prescription from the doctor, there were no issues.

      over 3 years ago
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    Side Effects (Swallowing problems): PEG tube-dependent for nutrition due to radiation shrinkage side effects on the esophagus

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