Since variations on this issue keep coming up, I thought I would add my
experience from when I worked for Blue Cross of California as their
first Maternal-Child Health Case Manager.

I authored two articles for Medela several years ago which apparently
are still kicking around:

Understanding Insurance Issues, MEDELA RENTAL ROUND-UP,  Spring 1989.

Insurance Terminology, MEDELA RENTAL ROUND-UP, Fall, 1989.

I wrote the articles to be very generic. Thus, the concepts are very
basic and still apply with little change. The Spring 89 article
particularly deals with submitting claims. My personal copies of the
articles are still in storage (since the Northridge earthquake - 3 years
this Jan 17th now! There is still rebuilding in my neighborhood...) but
perhaps Medela or someone on LactNet has copies.

> I have been hassling with the insurance company for a week
> now, and no response yet!!  Before hearing anything I had to say about the
> situation,  they told me it probably would not be approved!!!

First and immediately, I would request this baby be referred to the
insurance in-house case manager. The insurance-based case manager has
certain leeways for approval that UR (utilization review) nurses do not
have. The case manager may or may not simply approve the pump. I know I
did when I was the MCH Case Manager for Blue Cross of California.

In the meantime, for this mom, I would submit the claim immediately with
the prescription (and have the neonatologist write directly *on* the
prescription a *medical* diagnosis - and be aware that "premature" or
"SGA" doesn't count), expecting denial. Once denied, an appeal can be
filed quicker.

The first level claim is evaluated by "just a clerk" (often with HS
diploma only required for the position). Even if mom's insurance company
reviews claims by UR nurses, they often are not allowed to make any
decisions other than what their manual lists ("no" to breast pumps).
Often, HCPs don't review claims until the appeals levels. There may be 2
levels of appeal. I would include with the first appeal 2 or 3 (not
more) of *the best* articles demonstrating (here's the key) the
*cost-effectiveness* of BFing the premie. In a very nice letter (not a
"nut" angry letter), personalize the statistics of the attached articles
into what the cost savings could translate into for this specific baby
(have the parents call the hospital business office to find out total
costs for the baby to date, then divide by number of days for average
daily costs. Then do some simple calculation based on the numbers of the
articles.) Now this may not be what the insurance will actually
reimburse because they may have contracted rates with the hospital, but
it will give you some real numbers to work with. Your point will be
made.

It must be a letter. Forget the phone calls - phone calls are never
admissible in court, and practically speaking - phone calls, unlike
letters, simply can't be touched, viewed and experienced by the many
people who need to do so at the insurance company. Your clear message in
written form will remain clear as it passes through many hands.

At the appeal level (which may take 4+ weeks so be prepared to wait),
nurses and physicians within the specialty of pediatrics/neonatology
will review the request. It can often go to a third level appeal by the
medical review committee if denied at the second level. Both appeals
must be generated by the insured (parents). There is usually a formal
way to appeal; the insurance company will tell you what it is and to
whom it should be addressed at what address.

In the meantime, see if a local pump depot can obtain a scholarship
funding for the rental, or ask mom's church/temple or family to pitch in
to cover it. Several times, I have organized this kind of coverage
(parents are too stressed to do it - I their ask permission to contact
people for them. They then usually are stimulated to ask their own
families but are too shy to ask their church. So I ask for them. I have
never been refused - but then I don't ask very often.)

In a perfect world, we would not have to educate those who should know.
In the meantime, we can educate them one at a time.

Katharine West, BSN, MPH
Sherman Oaks, CA