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Well it has been 8 months since I completed my treatments with Proton Therapy. I finally received an answer to my appeal letter from my health care provider.
1/29/17 Letter received from BC/BS Fed:
For our purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.
The fact that one of our covered physicians, hospitals, or other professionals or facility providers has prescribed, recommended, or approved a service or supply does not, in itself make it medically necessary or covered under your plan.”
Based on all the submitted documentation, it was determined that the services were not medically necessary or appropriate for you. It was noted that the standard treatment options in this clinical setting include Observation, External Beam Radiation Therapy with Photons, Cryotherapy, Brachytherapy or Radical Prostatectomy.
Your treatment has been deemed not medically necessary
Contact Bob Marckini and or his organization' and ask for assistance in appealing this decision. I'm a little surprised that which ever facility provided your treatment did not check out your insurance company's willingness to pay.
Best wishes Don O.
Back in December of 2015 BC/BS DID give my wife the OK to go ahead with UF Health Proton Therapy. The hospital had also been given the OK for me to have proton therapy at that time. On Feb. 17th I received a voice mail from a finance employee saying I was approved and will start my 3 day work up and to bring in on Monday Feb, 22nd my out of pocket deductible of $5,000. So I did as she asked and started my work-up.
Throughout my 39 treatments I continually asked this finance person about my claim. She kept responding not to worry this is normal up until my last two weeks of treatment. Well I did worry and spoke with the Director of the Hospital who put his director of finance manager on this. This women was excellent. She told me and put in writing that if my BC/BS appeals were denied the hospital would NOT expect me to pay out of pocket since their finance person gave me the OK to start. So that made me feel better but I still as my post shows kept fighting. I am BC/BS Federal of Florida and I went in person to my local BC/BS Fed reps. They were very helpful also. They instructed me that BC/BS Federal allows me to after an appeal denial to send them a LETTER OF RECONSIDERATION. If that fails I have one more appeal to the Office of Personnel Management.
As I stated a few posts back BC/BS Federal has denied my letter of reconsideration on the grounds they feel it did not meet their requirement of being "medically necessary". BUT because back in December they gave my wife the WRONG information, on a one time basis they will pay the hospital all the charges but they are officially denying my claim. My wife and I fought and won this hard battle for coverage and to choose proton therapy.