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Insurance Process - Intacs For Keratoconus

Many health plans and insurance companies have established policies to cover most and in some cases all of the cost of the Intacs procedure for treating keratoconus.  Some smaller insurance carriers have yet to establish policies. Most all benefit plans require what is called pre-determination prior to you having surgery. The pre-determination process is an excellent opportunity for your doctor and you to educate the insurance provider about your condition.

The U.S. Food and Drug Administration (FDA) has approved Intacs to treat keratoconus under a Humanitarian Device Exemption (HDE).  A Humanitarian Device Exemption is a determination that a Humanitarian Use Device (HUD) is safe, has probable benefit, and it is not considered investigational/experimental.  An HDE approval allows for full marketing of the device.  A HUD is a medical device intended to treat or diagnose a disease or condition that affects, or is manifested in, fewer than 4,000 individuals per year in the United States.

In the event your insurance carrier doesn't have an established policy, the information within this website will hopefully help guide you through the process of helping your doctor educate the carrier, or in some cases your employer, about your condition and why other insurance carriers are listening to your doctor. Your doctor has most likely recognized the importance of the Intacs treatment as a better initial surgical option for you prior to a corneal transplant. Shouldn't your doctor be the person that determines what's best for your eye health?

How do I know I am a candidate?

First, your doctor will want to make sure you meet selection criteria for Intacs for keratoconus. Coverage is allowed in carriers who have established policies when the following criteria are met:

If you don't meet any of the above, the procedure becomes an out-of-pocket option. Most doctors offices offer financing options. Another option is the Citi Health Card accessible from the Intacs for Keratoconus website.

How can I help my doctor?

If the insurance carrier decides not to cover the procedure, which may occur due to several reasons, you have the right to appeal that decision. In the initial pre-determination, the role of the patient or family member is minimal however, there are steps that can be taken to help the process.

To learn what the doctor may submit to the insurance carrier, please review an example submission packet. This packet supplies fundemental information about the medical and financial differences between Intacs for keratoconus and a corneal transplant. Your doctor is the one that determines which is best for your condition - If it's Intacs, this packet will help educate the insurance carrier as to why your doctor has decided that Intacs is best for you.

Pre-Determination

Your doctors office will typically submit the pre-determination letter (see example) however, you can provide your employer with helpful information to assist you with obtaining reimbursement. In cases where your employer .... ATI has prepared an employer packet for you to give to your employer.

Evidence Based Consensus

The evidence based consensus points are for the purpose of providing more detail comparing Intacs corneal implants to the alternative comparable procedure – a corneal transplant. These are clear reference points often misinterpreted and improperly used in denials and negative policies.

Your Right To Appeal

If your insurance carrier denies coverage for an Intacs procedure, you have a right to appeal. Coverage is sometimes denied because the insurance carrier does not understand the treatment or the ailing condition. Consequently, providing information to them can be helpful. Appealing a coverage decision can be a lengthy process. Do not get discouraged. There are resources available to assist a patient or family member through an appeal process. Check your policy handbook for instructions on the appeal process offered by your insurance carrier.

Keys to a Successful Appeal

The appeal process ensures that any critical decision that affects your care is given the consideration it deserves. While the information on this website may be helpful to you, Addition Technology cannot guarantee your success in gaining coverage.

Educating the insurance carrier using evidence based facts provides you the best opportunity to overturn a denial. creating a "Patient Appeal" letter is often very helpful in providing your perspective about your condition. Addressing specific denials can help focus your letter to the insurance carrier. Feel free to review example appeal letters for “Not A Covered Benefit”, “Not Standard Of Care”, “Investigational / Experimental” and “Medical Necessity”.

Unfortunately, a claim may get misplaced in the mix of all the requests insurance carriers deal with on a daily basis. All insurance carriers have what's called a "Peer-Review Process" where your doctor can request your claim be reviewed by a 3rd party medical doctor in the same field as your doctor. Simply ask your doctor to request a peer review of your claim.

Additional Resources...

Below are addition resources available after the payor's appeal processes have been exhausted:

External Review Process:

Medicare and many other payors have contracts with independent companies to resolve disputes. If you are a Medicare plus Choice beneficiary and coverage for Intacs for Keratoconus is denied, the denial is automatically reviewed by the Center of Health Dispute Resolution (CHDR) for a final coverage decision. You may find additional information on the Medicare appeal process at www.medicareappeal.com. If you have commercial insurance (not Medicare), the initial denial is not automatically forwarded to a dispute resolution company. If dispute resolution service is available, either you or your doctor can request a review. Contact your payor for more information on their external review process/service.

Employer Group Assistance:

Employers who provide benefits to their employees through non-Medicare payors can often request that "an exception to benefits" be made that allows coverage for Intacs for Keratoconus. Call your Employer's Human Resources Department for benefit information and contacts.

Insurance Commissioner:

You can contact the Insurance Commissioner in your state to discuss possible ways to pursue coverage and payment through your payor. You can find an updated list of Insurance Commissioners at http://www.naic.org.

Attorney General:

Contact your state attorney general for assistance with an appeal process. A formal health care complaint must be submitted within a certain time period. A current list of state attorney generals can be found at http://www.naag.org.