Meds, Mind, Body & Benefits > Lipodystrophy & Metabolic Problems

Who will pay in California

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Oceanbeach:
Dear Forum Friends,

As my face has been wasting away, I have been dodging cameras for a few years.  That is why I never have an avatar with my own photo.

Last month, I was asked to be on TV for a News channel special on 25 years of AIDS.  I know about makeup, camera angles and lighting, it was the same for the other two local guys Harold and Greg.  They looked like themselves while I looked like death warmed over.  I borrowed a tape of the show from an employee at the clinic.

Since seeing myself or at least the man wearing my shirt and using my words and voice,  I just can not go out in public.  I spoke to a friend who is a medical biller at Kaiser Permanente, he has had Sculptura but he is a Kaiser member as well as an employee.  Tim said Medicare and or Medi-Cal (the California version of Medicaid) will pay for the procedure if the prescription is written properly.  My doctor said last year the vials cost about $3000.00 each and the procedure will require 4 vials, he also said he could do the procedure.

I live on disability and $12000.00 is much more than I make each year.  Has anyone had this done and paid for by either Medi-Medi?  Have the best day
Michael

www.Commission-on-AIDS.org 

bobino:
Michael,

First of all, let me say that I think the price your doctor is quoting is a bit high.  I've heard of getting Sculptra for substantially less.  So shop around.  Second, Sculptra has a patient assistance program, and it sounds like you would qualify.  I know that anyone making less than $40,000 per year is eligible, so you should also check into that.  If that fails, I think that there are buyers clubs that get Sculptra from Canada at a much lower price.  Many doctors will inject the material if you supply it.

Now, to answer your actual question, there are a number of laws on the books in California that require insurers to pay for procedures designed to restore a person's normal appearance where the appearance has been lost because of accident or disease.  Thus, in California, insurers are legally required to pay for these procedures where medically indicated.  There is a statute that makes these requirements applicable to Medi-Cal.  Despite the statutes, I understand that many insurers refuse to pay for Sculptra treatment.  The best course of action is to prepare a strong medical case in advance.  Get letters from your doctor that document your condition and, most important, the effect it has on you.  If you have a psychotherapist, get him/her to write a letter testifying to the adverse psychological effects the lipo is having.  Request a precertification from Medi-Cal.  If they refuse, then appeal. 

If you would like references to the laws that I am talking about, just let me know and I can provide them.  Don't give up on this.  I think that the law is on your side.

John

Oceanbeach:
Dear John,

I have started by sending an email to the staff nurse at the clinic describing how I feel about myself after the TV program, isolation and my earlier discussion with my provider last year.  That will get the documentation started from my provider.

I can contact the Clinical Case Manager and begin getting to the Psychotherapist on Monday morning.  Next, I would like to have the links to the laws as you discussed.  Thank you
Michael

www.Commission-on-AIDS.org

bobino:
Hi Michael,

The laws at issue are Welfare and Institutions Code 14132.62, Insurance Code 10123.88, and Health and Safety Code 1367.63.  The first provision is the one, I believe, that applies to Medi-Cal, and I'll paste a copy of the text here, since it's not too long.

The text of all California codes can be found here:  http://www.leginfo.ca.gov

The text of Welfare and Institutions Code 14132.62 reads as follows:

14132.62.  (a) Reconstructive surgery shall be covered under this
chapter, as defined in subdivision (c), when necessary to achieve the
purposes specified in paragraphs (1) or (2) of subdivision (c).
Nothing in this section shall be construed to require coverage for
cosmetic surgery, as defined in subdivision (d).
   (b) No individual, other than a licensed physician competent to
evaluate the specific clinical issues involved in the care requested,
may deny initial requests for authorization of coverage for
treatment pursuant to this section.  For a treatment authorization
request submitted by a podiatrist or an oral and maxillofacial
surgeon, the request may be reviewed by a similarly licensed
individual competent to evaluate the specific clinical issues
involved in the care requested.
   (c) "Reconstructive surgery" means surgery performed on abnormal
structures of the body caused by congenital defects, developmental
abnormalities, trauma, infection, tumors, or disease to do either of
the following:
   (1) To improve function.
   (2) To create a normal appearance, to the extent possible.
   (d) "Cosmetic surgery" means surgery that is performed to alter or
reshape normal structures of the body in order to improve
appearance.
   (e) In connection with the interpretation of the definition of
reconstructive surgery, a proposed surgical procedure may be subject
to prior authorization and utilization review that may include, but
need not be limited to, denial under any of the following
circumstances:
   (1) There is another more appropriate surgical procedure that will
be approved for the enrollee.
   (2) The procedure or procedures offer only a minimal improvement
in the appearance of the enrollee, as defined in regulations adopted
by the department.
   (3) Denial of payment for procedures performed without prior
authorization.
   (f) This section shall become operative July 1, 1999.

Basically the section states that you can have reconstructive surgery to create a normal appearance, and it seems to me that Sculptra treatment should qualify.  Note subdivision (e) and its requirement of prior authorization.

Hope that this is helpful.  Let me know if this works out.  

John

Oceanbeach:
John,

Thank you for the support and the help.  I printed out the links and will be all over them by Monday.  Have the best day
Michael

www.Commission-on-AIDS.org

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