Well the battle with my insurance continues. As I said my last post under "appeal won", my insurance only provided 1 unit (one visit) in regards to my VNS. I appealed that decision, and have a hearing on Feb 4th. My attorney just mailed me my copy of the exhibits they are planning to use, and it looks very bad.

I was implanted in 8/06 before CMS made their "noncoverage determination" against VNS for TRD, and they paid my whole bill ($50,000) without question as they were then approving on a case-by-case basis.
Then I went on to have adjustments for 2 years and thought everything was being paid as no one ever said anything too me, nor did I recieve anything from the insurance company. Then I come to find out, after I switched to a new Dr, my psychiatrists claims were NOT being paid, and he simply wrote the charges off without telling me.

Then, my device malfunctioned(or the settings where way off- not sure which) which is part of the reason I decided to see another doctor, you see I was this psychiatrists only VNS patient, and the rep only met with us once to help him figure the VNS out (not much training). So now I have a wonderful doc (a neurologist) who handles VNS patients on a regular basis, and we have both been fighting tooth and nail for them to continue the care of my VNS, which has relieved my depression. So now since I have appealed Medicaid, Medicaid has decided to recoup the $50,000 from the hospital where I was implanted on the basis that Medicaid "accidently paid the claim" 2 1/2 years after they paid it :Tantrum: , and it looks like I now owe $50,000. Which is bogus too because because at the time I was implanted I was told decisions were handled on a case by case basis, and I was told by the hospital everything was fine. So Medicaid can "say" this , have no proof that it was "accidental" , and the law apparently just takes their word for it instead of having them prove it.So now I have this medical device in my body (that helped my get my life away from the depression) and am waiting for the battery to die before I lose my "sunshine" again- now I have to be sick or possibly take my life when the depression returns, after feeling good for the 1st time in my life. I am terribly upset, I couldn't have imagined this ever happening.

Not only that ,since I have experienced problems with the device in the past what happens if it needs to come out for medical reasons? They won't pay for me to have the device interrogated to see if there is even a problem . I am also sure Medicaid will probably not pay for any medical bills relating to physical damage that could be potentially caused due to the device. My VNS model even has recalls on it. I had a recalled tire last year on my van, the company informed me and inspected the tire free. But a medical device is recalled and I find out on the internet, and there is no help offered.How can there be no rights in law for consumers of a medical device.

How can they just leave someone out there alone with what is essentially a pacemaker and not monitor a patient for potential problems with a "medical device". And how can Insurance companies get away with making so called mistakes and expect people to pay for their "error" Just doesn't make sense to me. I guess I opened a whole can of worms for fighting in someting I believe in, but I guess the law makes it to where I have no say anyway. :Tantrum:

Hi Adventurer06,

My goodness, when I read stories like yours about how insurance companies can make determinations one way and later do complete reversals really makes me wonder about our health system. Since my VNS was for epilepsy I had very few problems with my insurance, so I am not much help. But I know many on the board have posted similar issues and am sure they will be giving you input when they read your post.

In the meantime, enjoy your "sunshine" and continue to see the glass half-full. As the saying goes... "its not over til the fat lady sings!"

Hugs,
Cindy

If they both said O.K. at first I'd hold their feet to the fire!

Oh how I wish i could keep their "feet in the fire", labrat, but unfortunately they are simply taking Medicaid's word that it was an error, and my attorney said they are allowed to do this. Now a new fight may open up with the hospital, because according to Medicaid "they have now recouped the expense from the hospital', as the letter says that I recieved yesterday. So there is a real possibilty now that the hospital could try to sue me for the whole hospital/implant bill- I may be able to fight that but maybe not because it was verbal. I have spoke with my an attorney and digging through the internet itself thinking that there has got to be something in law to protect me and my rights. Unfortunately, I haven't found anything yet that say I have any rights, and I think its rediculous. I have many doctors records saying its medically neccessary to at least "monitor my medical device" , but that will all get thrown away by the judge because CMS is able to change their policy afterthe fact- and yes I've been told this is legal. I had my device implanted and medicaid had already paid the whole bill, and then 9 months later CMS issued its new decision to deny coverage for TRD. Now since they caught their error (which my appeal pointed out to them, they took their money back.
Then with what my doc did for 2 years without my knowledge, just writing claims off and not notifying me there was a problem with medicaid paying, that didn't help my case because of their claims history. I thought Medicaid was paying all the bills and it was only after to I switched to a new dr I discovered all this and the whole appeals process began. I never knew any of this before I had VNS surgery, but the dr/billing dept did know and may have thought they did me a favor but didn't and helped really hurt my case. I mean did he really think he was gonna be my doc forever, that it was fair I find out when I switched docs?I considered alot of different things, and had a cyberonics rep and hospital verbally tell me everything was covered, on top of the doc this telling me this was my last option because of my history and treatments tried. I was extremely very sick and was suffering tremendously before the VNS. So I did take a chance and have the VNS implanted. I never thought I would turn into a science experience in that 9 out of 10 docs offices I called even knew of VNS for TRD, or that the healthcare system would deny me care for my medical device.My doc informed me of what VNS was and game me a dvd packet and directed me to a cyberonics rep, and I thought about it, and doc and I agreed I had tried everything else, and I was implanted.Now that hell of my depression is gone, that is, until my battery dies, in which it will return. You see I already have had 2 malfunctions/operator error (1 of the 2) and each time it was shut off for the malfunctions, my depression returned. It was turned back on and I reached around 1ma., I was the depression free me again. I feel like the law has allowed me to recieve a sentence of sickness and hell maybe even death for no wrongdoing on my part. I may have 5 years or 50 days of battery life left to be well. That is like giving someone cancer back (I am a cancer survivor btw, so I know how that feels too), except at least with my cancer ,according to my faith ,I would be going to a good place to be and not suffer anymore. Also, I have no funds if this device damages my body or I need it out. I feel like I have had my heart ripped out and my hope taken away. I have 3 little kids I love very much, which is the main reasons I'm so grateful the VNS worked for me. I have very little support and I'm just trying to cope, and right now its really really hard. I think I'm still in a bit of shock, I thought every american has certain healthcare rights. I have no idea what I'm gonna do when my sickness returns. Feels bad. :So Sad:
Mary

Oh Mary, my heart breaks for you and others like you in the same situation. I wish I had the answers. Our health care system is a joke and a nighmare!

:D HI Mary!

I'm really at a loss for words for your situation other than I am so very happy you are doing well with your depression with all you are going thru.

I'm glad you have an attorney helping you appeal, and I am hoping for the best for you at your hearing on the 4th. I can't figure how Medicaid is saying they made an error without proving it. I hope the Judge makes them prove it before he (or she) rules on the case.

Have you google searched Medicaid + VNS? How about Medicaid + VNS appeals? Has your attorney cited you the statute that Medicaid can overturn their decision to pay and recoup monies even when medical necessity was proven? If you loose this appeal, is there a higher court you can appeal to?

Please keep us updated...thinkin' about ya!

B)

My hearing is tomm morning. Thanks to all who responded, I will let you know how it goes :excl: .

Mary

Good luck Mary! :clover:

Well, the appeal took place by phone with the administrative law judge as planned. I was thankfully more relaxed then I thought I would be, especially since I didn't sleep well at all last night. I think we were able to rebut most of what they said. It lasted about an 1 hr 45 min.

My attorney questioned medicaid, and then questioned me. Medicaid did not have a lawyer, and the nurse who represents them called no witness's and asked me very few questions. Then my lawyer questioned her, and i think he did a good job. I would of liked to of spoke again before he did final arguments but I still think I got my point of "medical necessity" across.

I spoke with my lawyer after the hearing, and he said he thought everything went well and saw some signs by the judge of trying to figure a way for medicaid to cover it. I submitted alot of medical records saying I had many benefits with the vns and also the info about the 2 malfunctions I already experienced, as well as cyberonics "safety alerts", and quite a bit of other stuff. I don't know when I will recieve a decision from the judge, but my lawyer says it could be at least a couple of months. If I lose I'm entitled to appeal again, and I will still have representation per my lawyer, but hopefully justice will be done and I will get the management of my device I need :-)
Mary

I hope everything goes your way Mary! Sounds good.

Thanks labrat :-)

:D HI Mary!

Sounds like you may have a good outcome! Your persistence has been inspiring! I hope you are feeling more at ease now that this part is over with.

B)

Hi Mary,

Sounds like your appeal went well and I hope you get a positive decision from the judge soon. Hearing that the judge was listening to the benefits you have gotten is very important and I am sure he will weigh this into his equation.

Hugs,
Cindy

Hi all,
Been awhile since I have been on here, but I figured I'd give you all an update. I did win the appeal. It took a long time, the state kept appealing, and I just got the final paperwork from the judge in June. They will be covering all of my adjustments, and I finally just recieved a reimbursement check from my docs office for all of the visits I have paid for. They are covering any/all adjustments to the device. I still have no idea how it will all pan out when the generator dies. I had some more problems with the device several months ago again except this time my food wasn't digesting and I was vomiting alot, it appeared that my vagus nerve was getting too much stimulation. And because I was having to pay out of pocket I did not go to the Dr right away and just taped my magnet for about 6 weeks or so. That wasn't good either because my depression returned 100%. Anyway long story short my device was lowered to 1.25 and I feel really good now- emotionally and physically. I really thought I was doomed but decided to fight anyway and I'm glad I did. I hope any of you looking for justice keep your chins up and keep fighting the fight : boxing : :D
Mary

Hi Mary! I am SO glad that you gave us an update and that everything is ok now. I often wondered how you were doing. Glad that you didn't give up with the appeals too. Hope that you continue to keep us posted. Hugs, Fay

:D HI Mary!

THANKS so much for your update! I am glad to hear you fought the good fight and won! It is so important to stand up for what is right and fair!

I am also really happy to hear you are having success with VNS. So often it is only the bad things we hear about, and a lot of times those who are doing so well just simply start living life, so they don't post. Please do keep coming back and let us know how things are going!

Take care!
B)

Hi Mary,

Great news! I'm so glad you stayed with the frustrating process and finally got the pay-off!!!!

Assuring that you have continued relief from the hell of depression is a worthy battle!

Congratulations....I hope the process in the future is a piece of cake.

Oreo

Thanks guys :) I've had the good with the bad in the VNS, but so far the good has outweighed the bad and I feel lucky. It was only accidental that I recieved this device- it turned out it really was an insurance mess up, or otherwise my insurance would not have paid. After all of this, the person who ended up approving and signing the $50,000 check lost their job. But in reality, after 20+ hospitalizations and dozens of meds I tried due to very severe depression I would probably be dead or locked in an institution somewhere without the relief of the VNS. The problems that I have experienced ( and was never informed about) with the device do scare me though. I really hope I have no more problems, as the thought of not being able to digest food is something I dread again. That was much more worse then the neckpain I had the 1st time something went wrong about a year ago- I absolutely hate vomiting. I guess I will count myself lucky for now and hope I don't have to trade my depression returning with my physical health.

:D HI Mary!

It is so frustrating that almost all of us were not told about alot of things that can go wrong with VNS, and bad side effects, etc. I am pro full disclosure so people can make an informed decision.

We have another Member here on the board that feels the same as you that the good outweighs the bad, and she is doing well. It is nice to hear good stories.

I am so happy things turned out great, and now you can sit back and let yourself get better and better! YEAH!!

Take care and hope to hear from you again soon!
B)

I know I wouldn't be alive if not for the VNS!

Ditto.

Hi Mary,

I think I may be the one Dispatch mentioned who is getting some good benefits but also some 24/7 crummy side effects. To be pretty stable and never in the pits of depression is an amazing gift!

I still take meds and see a counselor every week - but I'm functioning in the world again! I was pretty much house bound for almost 8 years...and suicidal for many years prior to that.

I admire you for working hard to do the best you can with VNS. It can be tempting at times to think it's too much trouble, but once the depression starts coming back, you know it's worth the work!

Dispatch and I have "talked" several times about how this is all a process. I had always hoped for a "cure"...and struggled for a long time before I could accept that my life was going to be quite different than the one I had started with.

I try to celebrate the lack of depression rather than be sad about the things that I can no longer do. My life needs be be fairly routine...I need lots of rest...I miss the personal benefits of working (I'm on medical disability), but have found ways to volunteer that allow me to be valuable in the community.

Take care! Oreo

Hi Mary,

I am so happy to hear that you won the appeal and are doing so well right now. I cannot imagine having to tape the magnet for 6 weeks, but at least you realized what you had to do to stay healthy.

Congrats again on the WIN!!!

Hugs,
Cindy