Insurance advise wanted.

[mrl]

Hi - My BCBS insurance (in Massachusetts) does not cover soft contact lenses for any therapeutic use, except in the case of keratoconus. I find this absurd, given that both Medicare and Medicaid will pay for these lenses as "bandage" contact lenses, for a multitude of problems. On the other hand, I believe Massachusetts BCBS will cover scleral lenses, which I'm scheduled to be evaluated for. I was not warned by my doctors, that soft contact lenses would not be covered. If that was the case, I might have asked for the scleral lenses instead! I have read on this forum, of people being denied coverage die PROSE lenses, which I'm sorry to hear. So my complaining about have to pay for a couple of soft lenses ($200 each), is nothing, compared to what people have to pay for PROSE out of pocket. And the fact that the plan is very clear about when these lenses are covered, seems to me that I have no case to stand on. Is that true? Is it possible at all, for me to be able to file a grievance with BCBS, and have any chance of winning, on the basis of the fact that it's standard procedure for eye doctors to use these lenses? Thanks for any advise. - Mark

[PotatoCakes]

Definitely file a grievance. Ask your doctors to write letters for you. I paid out of pocket for my PROSE, as well as other tests, etc that my doctor deemed unnecessary but you can definitely challenge the standard. Frequently insurers have people who know nothing making decisions. I say this because I closely know people (related to physicians) who have been either asked bizarre questions or denied for ludicrous reasons. For instance, I know one physician, when calling regarding his wife's hysterectomy, was asked if he was having the procedure. ???? Another situation, an individual who had been through a variety of therapies risked paralysis due to bone density (lack of) issues, was told they needed to go through extensive physical therapy prior to surgery that their doctor had already determined would render the individual immobile; the surgery was to ensure the spinal cord wouldn't be damaged in case of movement or fall.

The people making insurance decisions frequently have NO medical background whatsoever. You may not be successful but if you can prove the need, with your doctor's assistance, you very well may have your contacts covered. Both cases that I mentioned above, were covered. The second, the surgeon involved had to become quite involved but they were successful.