Dear Client,
This correspondence is in response to your recent Ask EqualityCare submission. Wyoming EqualityCare records indicate that the prior authorization for cochlear implants was denied as the client is able to communicate through speech. In order for a prior authorization to be approved for clients over the age of 21, the client must be unable to communicate through speech or other means to make their medical or basic needs known. The documentation that was submitted to Wyoming EqualityCare states that this is not the case. If you believe this is incorrect, please contact Rocky Mountain Ear Center.
If you have any additional questions, please contact ACS Client Relations at ------------
Sincerely,
ACS, Inc.
Client Relations
I have forwarded this email on to Advanced Bionics. This is just not right at all, how can they factor in how well one communicates, despite how badly they hear? Even FDA guidelines doesn't factor in communication skills, just hearing loss and how POORLY the person hears speech with hearing aids. This is an outrage!
6 comments:
Jamie Berke on Deafness on About.com mentioned you - Wyoming Wants Only Zombies to Get CIs
She looked around and found the exact wording used in your denial letter.
I looked through it also and it reads, as stated on page 74;
“1. Must be postligually deafened.
2. Must be unable to communicate through speech or other means to make their medical or basic needs known.
3. Must be highly motivated and have appropriate expectations to complete prescribed pre- and post-surgical treatment.”
The first is easily followed. The second? “Unable to communicate through speech or other means…” That essentially removes every known form of communications. Reading, writing, morse code, Braille, whistling, eye blinking, mind reading, miming, charades, sign language, head shaking/nodding, etc.
*head scratch*
The only thing that comes to mind are zombies and the undead.
The third is impossible to do if one follows the second requirement.
Therefore, their patients will be zombies from the local cemetery.
Where’s George Romero, zombie movie director, when you need him?
Utah Medicaid had a similar policy in 2001 that was successfully appealed. I didn't handle that case, but worked with the state Disability Law Center. Utah's draft policy was even more draconian as it said cochlear implants were not medically necessary because "deafness does not cause pain or suffering."
ASHA, HLAA, or the manufacturers should be able to readily tell you what other states have since implemented similar criteria. When I worked at Wyoming Medicaid in the 1990s they had no such criteria and I would suspect they copied it from other states.
Utah Medicaid had a similar policy in 2001 that was successfully appealed. I didn't handle that case, but worked with the state Disability Law Center. Utah's draft policy was even more draconian as it said cochlear implants were not medically necessary because "deafness does not cause pain or suffering."
ASHA, HLAA, or the manufacturers should be able to readily tell you what other states have since implemented similar criteria. When I worked at Wyoming Medicaid in the 1990s they had no such criteria and I would suspect they copied it from other states.
It appears that Equality Care may have confused the coverage criteria for speech-generating devices (SGDs) with cochlear implants. For example, persons with strokes who cannot speak or have full use of their extremites would fit the Medicare and FDA criteria for SGDs because they are unable to communicate through other means.
These criteria don't make sense for cochlear implants, as the best candidates are post-lingual.
So this may be a denial you can resolve just be talking to a policy person at Equality Care itself, and not its ACS contractor. I looked at a few current state CI policies so far and have yet to find this SGD criteria in theirs.
Thanks MHobratschk, you've been informative! The implant audiologist will be writing a letter with the doctor's signature stating how I need the implant and of how I could benefit from it, while mentioning my hearing loss levels and how that interfers with my ability to understand speech with hearing aids, and Advanced Bionics will also help out with the appeal process. Surely we'll get somewhere.
Hi CD.
I run a little website for the hard of hearing called The Hear Daily. Would you be willing let me interview you for a new section I am considering? Check it out (www.heardaily.com) and let me know.
Thanks,
Samantha
Post a Comment