How to get botox covered by insurance
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."
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.
Last edited by livecontent; 07-01-2012 at 11:50 AM.Source: www.city-data.com