Legal Question in Consumer Law in California
I manage a prosthetic company. We make high end cranial prosthesis for cancer and alopecia patients. Many of our patients medical insurance companies state in their policies under their DME coverage that prosthesis are covered at 100% and when they submit their claim they are denied coverage because they are saying its a wig. If you can visit our website at www.wiggin-out-salon.com you can see these are prosthesis that can last up to 5 years. They can sleep, swim, shower and continue to have active lives. Our patients have to wear the cranial prosthesis anywhere from 2 years if they have really short hair or in the case of having Alopecia for the rest of their lives. These prosthesis are really expensive to make and we are charging our medical clients just above our cost. They start at $2,500.00 and increase depending on the length of hair. I am desperate to help these patients get the coverage they deserve. I have been helping them submit their claims. I help them get all the required documentation. A prescription for a full cranial prosthesis from their physician and their diagnosis code and a letter of medical necessity for their emotional well being. Our documentation from our prosthetic company our Tax ID and the procedure code for a full cranial prosthesis L8043. Still over half of a patients are getting denied. Any help would be greatly appreciated. Thank you
1 Answer from Attorneys
It would be helpful to be able to refer these clients to an advocate who can then petition the denying insurance companies on their behalf in order remind them of their obligations to cover such a medical necessity. I think you will need to engage in an educational campaign, but it looks like you have done a great job ensuring the required documentation is provided. Having an attorney on-call who is familiar with this issue and who could be the go-to advocate would be ideal. If you would like to discuss this further, I would be happy to provide my thoughts concerning such an arrangement.
Regards,
Bryan
619.400.4929
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