Thursday, July 7, 2011

Full count

Have you ever felt like you were up to bat, the bases were loaded, there were two outs, and you had a full count... three balls and two strikes? No matter what you do, it has the potential to be bad? That's how I've been this week. I'm living with a cloud of uncertainty hanging over my head and no clue what is going to happen or when. I have no idea when the pitcher is going to throw that curve ball at me. Will I hit the ball, get a walk, or strike out??? It's a crapfest. My review was due by 6/30. It's now 7/7 and I still haven't had it. I walked by today and saw that she was typing on it.

I know that taking this long to do something that was due a week ago just cannot be good for the home team. But, at this point in my life, I truly don't care. I just want the ball to be thrown and the inning to be over. I either win, or I lose. Either way, I think I win. I'll be without the stress and the everyday of wondering just when something will happen. I am not perfect and I am going to make mistakes. I'm tired of looking over my shoulder, afraid to say or do anything because it might be the "one" to tip the scales. Just be done with it. Put me out of my misery.

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On another note, got my second denial from insurance. Bat rastards. I'm totally irritated with them. So I sent them yet another letter and will have some kind of answer within 15 days of the receipt of my appeal. That was last Friday (but, because of the holiday it may not have gotten to them until this Tuesday). If they tell me no again, I'm not sure what I'll do. I do want to say - and be very clear - that any frustration I write about, speak about, or whine about is only VERBAL. It is in no way a hint, plea, or request for any kind of financial assistance. No one has said, but I don't want there to be any gray areas. As much as we've had on our plates financially in the past 3+ years, I've never asked anyone for any money or help in any way except some manual labor. I've been blessed with gifts from friends (microwave for Ron comes to mind) in some cases, but never really asked or expected anything of value from anyone.

Now that I've cleared up that potential issue, here's my latest letter to the 2nd level appeals board;

To whom it may concern:

First of all, I must say how extremely disappointed I am that the 1st level appeal team did not approve my request for the bone anchored hearing system to be considered a prosthetic device. I laid out very good, clear reasons why is it more than a hearing “aid” (which relies on air conduction to amplify sound) and is a true prosthetic because it converts sound waves through bone conduction. Although the system is commonly referred to as the BAHA (Bone Anchored Hearing Aid), it’s description has changed and evolved over the years to more adequately describe it’s function. Just because an acronym includes “aid” it does not mean that “aid” is the correct terminology. While I appreciate the inclusion in the rejection letter of the schedule of coverage benefits, it was not necessary. I know that hearing aids are only covered at $600 per ear every three years.

I’ve tried hearing aids and because I have NO hearing in that ear, there are no sounds to amplify.I have extensively researched Cochlear Implants (which is COVERED as a prosthetic device) and it more accurately fits a description of an “aid” because it consists of tiny microphones which AMPLIFY sound via the auditory nerve. The Cochlear Implant is also quite a bit more expensive. I’m thrilled that the outpatient surgery is covered at 100%, which is the most expensive portion of this system. The device is approximately $8500 and I cannot get the implanted part without the external part. Via Christi does the billing for this surgery/device as a package – not as individual items. I cannot do part without committing to the other. $600 coverage for an $8500 item is crushing to my spirit and to my ability to live a somewhat normal life – the same life that those who receive Cochlear Implants are allowed to live.

I have done further research to demonstrate how this system has evolved over the years. Please see http://www.ncbi.nlm.nih.gov/pubmed/21389702, which discusses how Oticon Medical introduced a new bone-anchored hearing system in 2009. The article states, “Oticon Medical introduced in 2009 a new bone-anchored hearing system, the Ponto system.” What is a BAHA? http://www.umm.edu/otolaryngology/baha.htm states “The Baha consists of three parts: a titanium implant, an external abutment, and a sound processor. The system works by ENHANCING NATURAL BONE TRANSMISSION as a pathway for sound to travel to the inner ear, bypassing the external auditory canal and middle ear. The titanium implant is placed during a short surgical procedure and over time naturally integrates with the skull bone. For hearing, the sound processor TRANSMITS SOUND VIBRATIONS through the external abutment to the titanium implant. The vibrating implant sets up vibrations within the skull and inner ear that finally stimulate the nerve fibers of the inner ear, allowing hearing.” A Cochlear Implant is a small device that consists of a microphone (which picks up SOUND from the environment), a speech processor (which arranges SOUNDS picked up by the microphone), a transmitter and receiver/stimulator (which processes the signals). If a bone anchored hearing system is to be considered an “aid,” then it is only reasonable that a Cochlear implant also be considered an aid. A Cochlear implant more closely deals with sound while the bone anchored hearing system deals with bone vibration/transmission. In truth, neither of these two devices truly amplify SOUND and neither of these devices are hearing AIDS. A hearing aid is a device that “assists perception of speech or other sounds.” A hearing aid amplifies existing hearing; the BAHA replaces hearing, just like a prosthetic limb replaces an amputated limb.

Most large insurance companies follow trends set by Medicare. According to the National Institute on Deafness and Other Communication Disorders (http://www.nidcd.nih.gov/), “Medicare does not cover hearing aids for adults… Since Medicare has declared the BAHA a prosthetic device and not a hearing aid, Medicare will cover the BAHA…”

The University of Maryland Medical Center, Center for Auditory Solutions has the following list: BAHA implant, Cochlear Implants, hearing aids, tinnitus and hyperacusis program. (http://www.umm.edu/otolaryngology/auditory_solutions.htm Notice that BAHA implant is not included in the hearing aid category, but rather is its own category, just like the Cochlear implant has its own category.)

I cannot comprehend how our insurance company can cover an implant for a man to have sex but cannot cover an implant so I can hear. It is just unfathomable. I am only asking for a one-time coverage of the cost of this processor at the “reasonable and customary” rate that Via Christi contracts with you for. This would enable me to receive the same benefits that those who get Cochlear implants receive.

Now, we wait.
 
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Tuesday, I sent out a couple of packages. One went to Jo-Anne (who won my "taste of Kansas" drawing) and the other to another friend. Once I'm sure she has her package, I will post a picture of what I sent. I didn't take any pictures of what I sent Jo-Anne so she'll just have to post them to her blog. I'm currently (also) working on a scrapbook for someone else but I need to print some more pictures before I can finish it. Soon... I hope... soon.
 
It's bedtime in Kansas so I better hit the sack. I am looking forward to my weekend off.
 
I'm going to try and catch up on my blog reading/commenting this weekend. Saturday, we're going to go visit my mother, but I'll be free on Sunday. Ron's taking a road trip with some friends (great for him to get out with someone other than me!) so I'll be able to catch up.
 
Until then, God bless you all!
 
t.

6 comments:

SkippyMom said...

Great letter Tee. I swear I wish they would just approve it as it makes no sense why they won't. If this one doesn't work is there someone even higher up you can go to? Someone has to see the sense it makes to cover the procedure. BAH!

Great wishes that this is resolved and you can hear again. Big Dummy Insurance companies.

And work...well, y'know what I say. Go eat that apple [or carrots] and enjoy the heck out of it. giggle

Green Girl in Wisconsin said...

I don't get it--why they can't approve something that makes so much sense. Rat-bastards indeed.

Kathy's Klothesline said...

I can only hope that someone intelligent reads your letter. You have laid it all out in a very reasonable fashion. It all depends on the one reading it. I know what you mean about waiting for that next disaster to hit. Just get it over with! Still ...... sending good thoughts your way.

Libbie said...

Oh man Teresea...What a hard time you are going through right now! Seriously you are stacked! I will pray that this season passes quickly & that you will be showered with blessings. So sorry to hear about all you are enduring mow. I am going to stop & pray right now.

Sending love!!!
Lib

Thisisme. said...

That was a brilliant letter that you wrote, Teresa. You've obviously done so much research on it. Why does everyone have to fight so flipping hard to get anything that will make their lives so much easier. I do so hope that they will change their minds and come down on your side for once! That will be good for Ron to go on that road trip. Take care my friend. Blessings.

Bouncin' Barb said...

Fabulous letter Teresa! The squeeky wheel gets the oil so don't stop if they reject you. Keep annoying them. Hope your weekend is relaxing. I've never known reviews to ever be delivered on time so I wouldn't sweat that yet. Keep us posted. Hugs sweetie.