BCBS Anthem PPO - Written in OHIO

nst1975 · 07-08-2008, 06:13 PM

Hi there ~
I am new to this forum... was diagnosed with PCOS and have been having trouble with my insurance company. They do not cover the fertility treatment but cover the diagnosis. My specialist monitored me through ultrasound and bloodwork 5 times in during my cycle and they only covered 2 of the 5. They claim they need more information from the doctor. Has anyone had this issue before? Also, where do you find the mandated states for fertility treatment? I may need to switch my job!
Thanks!

Christie_1981 · 08-20-2008, 11:32 PM

Just wondering if you ever figured this one out.. I have the same insurance and am curious. So far, my ultrasounds and bloodwork have been covered, but I noticed they paid 1 from my last cycle and not the other 2 yet. I'm just waiting for them to deny them, although when I talked to them on the phone I must have asked 8 times "so ultrasound and bloodwork are considered diagnostic" and she told me yes. I even asked if it was when it was in a cycle, and she said yes... so we'll see.

Bertiebugg · 08-21-2008, 10:41 PM

You can find information about the state mandate http://www.fertilitylifelines.com/pa...atemandate.jsp

Ohio
Mandates HMOs (but not other types of insurers) to cover infertility treatment as a "preventative" benefit. The treatment must be "medically necessary," and the Ohio Department of Insurance has ruled that GIFT, ZIFT and IVF are not medically necessary.

Maryland
Mandates insurance carriers that provide pregnancy–related benefits to cover IVF after a two–year wait following diagnosis, with no wait required for certain diagnoses. Insurance carriers are not required to provide this benefit to businesses (group policies) of 50 or fewer employees. Religious organizations can choose not to provide coverage based on their religious views. A carrier may limit IVF benefits to three attempts per live birth, not to exceed a lifetime maximum benefit of $100,000.

Basically if the services are considered diagnostic and medically necessary then your insurance will cover it. However, if you are going through a fertility cycle... and they determine that the services were in relation to that cycle then the services will not be covered. They can make this determination by requesting chart notes from your provider or by the diagnosis that is being billed.

The way I usually explain this to people is that the plan covers to diagnosis and to treat the underlying causes but will not covering anything inconnection with getting them pregnant. So your dr might do 8 ultra sounds in a month to see if your body is doing anything on its own this would be considered diagnostic.... but if your doctor says well it looks like you've produced an egg lets give you a shot to release the egg and do another ultrasound in a couple days.. this would be considered a cycle to get your pregnant and would not be covered.

I hope this helps

Christie_1981 · 08-24-2008, 02:54 AM

Unfortunately I don't benefit from my state's mandate because my company is self insured.

The whole diagnostic/treatment seems to be such a gray area. I talked to my insurance company three times now and still can't really get a straight answer. They tell me infertility treatment is covered when it for diagnosis and treatment of an underlying medical condition, but isn't PCOS an underlying medical condition, and isn't annovulation a symptom of said medical condition? Then the other tells me yes bloodwork and ultrasound are diagnostic, even after I asked if it was during a cycle of treatment. The only thing my insurance specifically said was IUI and IVF are not covered.

I mean technically, bloodwork and ultrasounds are diagnostic tests, they aren't treatments.

So two of the people I talked to I wasn't specific with, they only said diagnosis was covered. The last lady I was extremely specific with (short of giving her the billing codes..) and she told me the ultrasound and bloodwork is covered. I told her I really needed to know if it was or not to decide if I would go back to the RE, and when she told me it was I made the appointment. If they come back and deny my ultrasounds and bloodwork, I will be really upset. And there won't be much I can do about it, I mean I can call them all day long and say Marsha said at 6:30 PM on 8/5 that bloodwork and ultrasounds are covered, but really what is that going to do...

At least I do know that the day 3 bloodwork and ultrasound is definitely diagnostic. Now the day 12 ultrasound and bloodwork is the gray area, since I would be taking Clomid and they would be seeing if the Clomid was working.

The RE is billing under the PCOS code, so I guess that helps.

It's added stress I don't need. I'm frustrated with the whole situation since my company was bought out last year and prior to Anthem we had Cigna, which would have covered the infertility diagnosis AND treatment.

Bertiebugg · 08-24-2008, 01:44 PM

Christie I would say from what you just told me that the day 12 ultrasound would not be covered. However, since you were quoted that it would be covered you can appeal. I'm sure your insurance companies like most record all their calls... and leave notes every time you have contract with someone. If the claims are denied... APPEAL! You were quoted that the services would be covered then they need to cover them for this one cycle or until you are told differently. So if you have 2 cycles with ultrasounds etc and then the insurance comes back and says that its not covered, then appeal because they misquoted your benefits.

IsabelleGrace · 08-24-2008, 11:03 PM

I would suggest that you speak with you benefits administrator if you have any questions regarding your coverage. Coverage varies depending upon what plan "specifics" that your company opts for with regard to your plan. Please check with your company's benefits adminstrator. If this is member sevices at a (800) number, then that is also acceptable. As a BCBSFL employee and member, I find myself referring to the (800) number CSR more often that not. Knowledge is king! Good luck sweetie!!!!