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Old 05-15-2012, 08:52 AM
 
Location: Pawleys Island, SC
1,836 posts, read 2,564,164 times
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Does anyone have experience with Botox injections for spasticity/involuntary muscle contraction? My mother's neurologist is recommending it for treatment. It's FDA approved and quite a bit of info online, but nothing on Medicare's website. I called their support number, but rep could not tell me whether it is covered or not by Medicare. If anyone with Medicare coverage has experience with this treatment, I would appreciate your feedback regarding how you made out with Medicare reimbursement. Thanks for your help.

Last edited by golfgal; 06-25-2012 at 07:48 PM.. Reason: not necessary
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Old 05-15-2012, 09:10 PM
 
Location: Missouri
5,933 posts, read 14,941,926 times
Reputation: 4561
Go here:
Find Contact Information of Organizations for Medicare
Choose Organization: SHIP - State Health Insurance Assistance Program
and then select your state.
Your local SHIP will be able to answer this question for you.

Having said that, several years ago I worked with a Medicare patient who received Botox for a similar condition, and it was covered (subject to copays and deductibles of course). I would suspect it would be covered for your mother as well if it is FDA approved for her diagnosis.
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Old 05-17-2012, 09:12 AM
 
Location: Pawleys Island, SC
1,836 posts, read 2,564,164 times
Reputation: 3885
Christina - Thanks for your response. I've heard good things about SHIP from other forum members, unfortunately, my attempts to get info from our local office has been less than encouraging - unreturned calls, no specific information, reading from scripts, etc. I tried calling Medicare directly. The rep was courteous and patient, but couldn't provide any useful info. Their only recommendation was to have the provider call their Medicare number, and they should be able to determine whether it will be approved. I'm currently trying to get her doctor's office to do that. Again, thanks for the feedback.
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Old 06-08-2012, 11:44 PM
 
Location: Cleveland Heights OH
13,596 posts, read 10,666,963 times
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First of all the good news I hope. My neighbor had to get botox injections for her eye muscle contractions and Medicare paid for them. SHIP can help you choose which Medicare supplement or Advantage plan to choose but they cannot tell you whether a specific item can be covered.

You are on the right track having your mother's doctor can call the phone number listed on her Medicare health insurance card for a pre-approval. That way you can find out for certain whether or not her botox injections will be covered. I think that for a medical condition like hers, they probably would be.
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Old 06-25-2012, 06:54 AM
 
Location: Virginia
18,717 posts, read 15,628,661 times
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When you get Medicare approval for a condition like this, do you have to get the approval in writing?
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Old 07-01-2012, 11:09 AM
 
1 posts, read 4,508 times
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in regards of your mom's condition you have to remember the doctors office have to do all the necessary paperwork for their patients. It is not your job, but anyway if your mom have medicare/medi-cal they have to request an authorization to get it approve, but sometimes you have to get on their backs to get things done, your mom does not pay for anything.
Believe me it works
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Old 07-01-2012, 12:16 PM
 
4,931 posts, read 8,804,991 times
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From my experience in contacting Medicare, many of the gatekeeper people who answer the phones do not capacity to answer that question nor should they have that ability because it is the responsibility of the Medicare approved Insurance Carrier to make that determination which your doctor's office should contact for pre-approval of treatment.

The data and information does exist but it exist at CMS which is the Center for Medicare and Medicaid Services Home | Centers for Medicare & Medicaid Services, the agency that oversees Medicare.

There is a Medicare Coverage Database but it is complicated and requires professional knowledge of medical terms and as such "The MCD is intended for use by Medicare contractors, providers, and other healthcare industry professionals."

Medicare Coverage Database

I think it is a great suggestion to contact the SHIP for your State and request assistance.

As given by another poster, your medical provider should be able to determine if botox is approved for your condition and you should not have to do any work to make an assessment. The problem is that if they make a mistake in treatment and billing, they demand that you pay and they abrogate their responsibility by stating that if you are responsible for the bill, if your health insurance fails to pay. Also, you can contact your insurance carrier to get a written pre-approval of payment for the treatment which should have the professional staff to make such assessment or maybe not as I have found out in the past. Of course that is what your doctor's office should be doing and let the insurance carrier deal with the complications of Medicare decisions and coverage. If you cannot get the incompetent billing clerk to contact the insurance carrier for pre-approval, then seek another doctor.

Many of these Physician Offices are just "hole in the wall places" with billing clerks that have minimal knowledge and capabilities. That is why I gave up on dealing with their ignorance ,years ago, and I have selected a competent and professional staffed Medicare Advantage Plan which does not go to Medicare for every reimbursement as they are given a lump sum for care. They know very well what is covered under Medicare and have defined protocols and formularies for procedures and medications for their providers. I have chosen Kaiser Permanente in Colorado years ago and I have had great success, even when I have appealed their treatments.

Kaiser have a defined and effective initial steps for appeals within their organization and they give you the required information to appeal further to Medicare. If you go to a small doctor's office they do not have the staff, the time or the expertise to process an internal appeal and will just tell you to go get care somewhere else, if you do not pay their bill or do not like the care. You then will go to some of these sloppy insurance companies and they again do not have an effective mechanism for review or care to review in your favor.

Livecontent

Last edited by livecontent; 07-01-2012 at 12:50 PM..
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Old 07-01-2012, 01:08 PM
 
Location: Wisconsin
14,380 posts, read 19,160,414 times
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Quote:
The problem is that if they make a mistake in treatment and billing, they demand that you pay and they abrogate their responsibility by stating that if you are responsible for the bill, if your health insurance fails to pay
Exactly. Textbook on billing issues, as I recently learned - my experience verbatim to what you cite. Critical to find a provider which bills properly. I got it fixed (I think), but only after reporting provider to the BBB for incompetent and uncooperative billing department which was too lazy to provide UHC w/proper paperwork.

Lo and behold, two days after I complained to BBB, provider FINALLY contacted UHC. Bill was paid four days later.

I am on Advantage w/UHC and never had a problem until recently. Needless to say, I'll never see that provider again.

Last edited by Ariadne22; 07-01-2012 at 01:24 PM..
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Old 07-01-2012, 02:15 PM
 
4,931 posts, read 8,804,991 times
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Another annoyance which gets me angry. Your plan, for example, requires you to go to a certain doctor that is on their approved physician list. However, they have a disclaimer that it is up to you to ascertain that information is accurate and the doctor is still accepting the payment schedule of the insurance carrier. How would you do that in an emergency situation where one doctor in the emergency room may or may not be on the list or has left the plan. In addition, you will find that doctors even practicing in the same office agree to different insurance plans. You then get an EOB (Explanation of Benefits), months latter, and the reimbursement was not as example, let say 90% but 70% because the physician was not approved. Of course, then you will get the bill from the physician who wants his payment and if he is not on the plan will want more. These idiots in the insurance companies can not even keep an updated correct list, even when it is easily corrected online. Talking to their ignorant customer service people before treatment does not help as they are only looking at an incorrect list.

That is another bunch of bull in which I have decided to use Kaiser Permanente. I know that the physicians are on their plan.

I am very well versed in Insurance issues, as having been very sick and disabled; I have been an advocate for my aged parents with healthcare. It is a very difficult and annoying industry and when I choose to be not nice and forceful, they know it. I have had strong words with all kinds of people from physicians to clerks to government personnel when the need is necessary.

One of the tools I use when I talk to to people for insurance and medical care is that I record my conversations. I legally follow all the rules that apply for interstate and intrastate recordings. I have used these recordings to affirm my cases and sometimes all I need is to replay what has been said to bring some of these deceivers, liars and incompetents into compliance.

Livecontent
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Old 07-01-2012, 02:56 PM
 
6,978 posts, read 16,628,511 times
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It may be approved one week and then changed the next week. If she needs it, she should get it and arrange to self pay. If she doesn't need it bad enough to pay for it herself.......well, think about why Medicare is going down the tubes.

But seriously, her doctor should see the need to get the prodedure approved ahead of time. And then, surprise! surprise!, they may approve the PROCEDURE, but not the medication, etc. for it.

For example.... I had cataract surgery in both eyes. They approved the surgery, but they didn't approve the medications to dilate the eyes, calm me down, deaded the pain, etc. I ended up paying amost four hundred dollars for medication on an approved procedure because the medications weren't on THEIR approved list.

Sometimes, Medicare isn't the freebie you think it is. And the worse part is that if Medicare doesn't APPROVE something, your insurance won't pay either.
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