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Insurance Coverage and Diagnosis/Procedure Codes


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I thought that if you went to an in-network provider, all tests/procedures ordered by that in-network physician would be covered. But our new insurance said no, the CPT procedure code(s) for the tests must be medically necessary (according to their definition) for the CPT diagnostic code given by the doctor on the claim. 

Our daughter has been given different diagnoses by different doctors, ie, POTS, Orthostatic Hypotension, and CFS. The doctor that said she had Orthostatic Hypotension later said she no longer had it and was deconditioning and chronic fatigue. With any new doctor, we do not know what he will diagnose, which means we might have to pay full non-contracted price for any testing and it will not apply towards our deductible.

The insurance company said that when you go to an office visit, you can ask the doctor for the diagnosis code and for any tests he wants ordered, you can ask for the procedure code. Then you can come home and call the insurance company and give them both diagnosis and procedure codes and then they will tell you if it is medically necessary or not. Then if they will cover it, you return to have the testing done a different day. That seems so cumbersome, and the insurance customer service said that people were doing that.

Have you had to pay for autonomic testing because insurance would not cover those tests due to a CFS diagnosis or Orthostatic Hypotension? We do not know beforehand what doctor will diagnose, and it sounds like the tilt table can be failed even when a patient has POTS or OH.

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I would try to have the same doctors within the same "clinic". For instance most of my doctors are within Lexington clinic. That way they won't change the diagnosis. 

I have had testing done on different days.

We are still waiting to do the echo for my son locally and then see our specialist to start him on florinef. It has been 2 or 3 weeks now. 

It takes longer but I would hate to have my testing cost out of pocket. 

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Yes. This is how it works. This is why the doctor you use matters. If they don't code it correctly, you can easily be in bankruptcy. This is why going to a center that specializes in dysautonomia was crucial for me. It got things through my insurance because they do nothing but dysautonomia. It was a hassle, but worth it for me. I also specifically paid more to have a PPO open choice type of plan so that I wasn't at the mercy of an HMO and their set of doctors.

Your doctor 'can' refile and recode those claims for you, but often they won't. You can try to appeal them with the insurance, but you would need supporting documents from your doctor and it sounds like he doesn't support it. Do you have prior doctor's opinions that you can use? Most likely you can't get in to a dysautonomia center in time to appeal those claims.

Dysautonomia is not well known and coding hasn't evolved to cover us the way I would like. This is what I do with my life now. I'm either sick or managing the administrative side of my illness. It is like a part time job until something blows up and it is a full time job. Then I struggle to handle it myself. I'm still waiting to see if I am getting stuck with a $4200 bill. At least I hope that is all it costs. They may still charge me the uninsured rate too.

I hope you can get this stuff covered. You have a better chance with private insurance than with Medicare or at least that was my experience. 


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@Trying - I had 3 different insurance companies since onset of my illness but most of my testing done for POTS were covered. The only problem I had was when I was on Medicaid and my specialist is out-of-state, so his visits were not covered. My PCP has not ever had a problem getting testing approved for dysautonomia because I have so many symptoms - like syncope, HTN, seizures - from POTS that they usually qualify me. Now - I understand you recently moved and Jennifer saw a specialist for CFS - if they diagnosed her with POTS then that is a diagnosis in her permanent record, it should be used for any testing or specialist visits. Depending on what test your doc is ordering this diagnosis code should be enough to get covered. 

www.mdedge.com/clinicianreviews/article/81530/cardiology/postural-orthostatic-tachycardia-syndrome …

According to this link the ICD 9 code for POTS is 427.89

It should be the responsibility of the ordering physician to get approval of tests but ask him to include this in your coding. As long as you have the documentation from the CFS center that she has POTS you can use this code. Also - CFS and deconditioning are both symptoms of POTS, so the POTS diagnosis should cover both of those ). 

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Hi Trying,

I am sorry you are dealing with the funding side of things as well. Sometimes I envy the care people in the US have access to (I am in the UK where state healthcare is free but very basic & limited especially for uncommon conditions), but I see there is a dark side to the system there too. 

If it is a TTT specifically that Jennifer needs, I have heard of people who were denied by insurance at first having success with approval if the word "syncope" is used (that is if she does or has ever passed out from it).

Best of luck getting access to the tests.

B xxx

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