I have a patient who is a paraplegic that has a microprocessor C-Brace that he has had to pay out of pocket with fund raising from his community and family as PEHP has denied as experimental and non covered. This bracing has clinically improved the patient's quality of life documented by clinic improvement in mobility and less injuries to do falls vs the manual system. Medicare has assigned a specific code L2006 and as of 10/22 Medicare has assigned pricing as well to the updated HCPS code. The patient in question has PEHP and has been denied coverage as the master policy will not cover this microprocessor C-brace technology unless he is a amputee. Does anyone have any experience in Utah with the Utah state retirement board hearing process? This patient had extensive clinical documentation showing the contrast of the use of the manual system vs the C-Brace technology in his previous hearing in 2015 and as the brace needs to be replaced, PEHP has again denied coverage as an exclusion to the master policy unless patient is an amputee. Is there no recourse for patients to get insurance companies to pay for proven medical treatment in the state of Utah? Medicare has an LCD and payment policy and yet PEHP will not look at a case by case patient as they stated", if we approved one for you we would have to approve it for all". Please any advice would be welcome.
Ann
Ann