Guest jcs Posted December 4, 2002 Posted December 4, 2002 Can an insured health plan limit physical therapy visits connected with early lymphedema after a mastectomy? The plan limits physical therapy visits to 20 per year. Is this allowed to apply to PT for lymphedema? I see that WHCRA allows for the plan to apply deductibles and coinsurance, but appears to be silent on other restrictions/limitations. Thanks! jcs
Guest SMW Posted March 11, 2003 Posted March 11, 2003 We do not seem to get any answer regarding the wording "the treatment OF PHYSICAL COMPLICATIONS at all stages of the mastectomy, INCLUDING LYMPHEDEMA." The insurance company acknowleges prosthesis but not on-going physical therapy as necessary. Our insurance stands firm on 20 PT visits per year. My lymphedema requirements are used up in 3 months as I have 5 areas of lymphedema. I read the Women's Health and Cancer Act of 1998 to cover this, however my insurance doesn't see it that way. They only do prosethstic items. HELP!
Guest jcs Posted March 11, 2003 Posted March 11, 2003 SMW, I've been through two levels of internal appeal with my insurance co. (probably the same co. as yours). It is now under review at the State Insurance Dept. I had also contacted the US Dept of Labor. Their reply was that this limitation is a gray area of the law right now. The DOL is just STARTING to draft some regulations, but these might not even cover this specific topic of PT limits. It might be close to a year before we even see proposed regulations. I agree with you that the law doesn't seem to allow any limits beyond deductibles and coinsurance, particularly when compared to the Mental Health Parity Bill of 1996 which specifically addresses annual limits. WHCRA and the Mental Health Parity bill are right next to each other in ERISA, so there should be some legal weight given to the lack of other allowances in WHCRA compared to the earlier Mental Health bill. Unfortunately, it will probably take a court case to settle the proper interpretation of this. In the meantime, you should pursue appeals as high as you can go (including any appeal to your state insurance department). I wish you all the best of luck. I will post any update from the state insurance dept ruling once I receive it. jcs
Guest jcs Posted March 20, 2003 Posted March 20, 2003 The insurance company ended up paying on the additional PT visits, presumably due to the inquiry by my state's insurance dept.
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