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Getting insurance companies to cover stuff -- when it's needed...  

post #1 of 5
Thread Starter 
Okay...granted...most moms can successfully breastfeed without the use of pumps, LC visits, etc.

However, when there are special circumstances, who can we convince insurance companies to cover this stuff?

Because of DS's poor latch (actual inability to latch correctly), we need follow up visits. We've seen the LC once (courtesy of a rockin' lactivist mama) and now we have a hospital grade breastpump (also courtesy of the same mama). We *might* have a fighting chance. But at this point we also need (according to the LC, not the ENT who has his head up his you-know-where)...a visit (possibly multiple) to the dysphagia clinic, a visit (possibly multiple) to the head of lactation at UNC Hospital, and more than likely breastpump rental (hospital grade) for as long as I'm planning to breastfeed. I guess we'd only need the breastpump long term if the dysphagia clinic and/or the head LC can't help us...

Anyhow, my insurance company won't cover any of it. None...zip...zilch...nada. They flat out don't cover infant feeding issues UNLESS they are unable to take a bottle. Oh, if they can take a bottle, then they are fine. And let me tell you, I've called these professionals and visits to them aren't cheap. DH has put his foot down and said, "no...we just can't afford it..." (trust me, we did the breastfeeding vs. formula cost comparison and so far breastfeeding has cost us much more than formula would (teas, herbs, domperidone, etc.).

So...what is going to take to get the insurance companies to see the importance/benefits of breastfeeding and to get things changed or at least headed toward change.
My baby *will* take a bottle, he just can't nurse. I've tried finger feeding him and he gets so mad. My fingernail is holding his tongue in the "breastfeeding" position and he gets so angry. With the bottle, he can hold his tongue any which way he chooses and he still gets milk *drip drip drip* and he's happy with the SNS because it gives him a drip drip drip, too. So he's basically using my breast as a bottle and taking all from the SNS, but not stimulating my milk production. So my insurance company says as long as he'll gain weight and be healthy with a bottle that he technically doesn't have a feeding issue...
post #2 of 5
well, my baby can't nurse most of the time, so I EP. I work for my insurance provider, and they won't help me. Then again, he's a preemie and they won't cover synagis either, so.....

I'll tell you what I've seen work in appeals for other matters. Get letters from any doctors/LC's/etc. that you can. Make sure the LC is an IBCLC, as insurance companies are only going to pay attention to someone who's licensed. In addition to your provider(s), write your own letter that outlines the potential cost to your insurer. For my Synagis appeal, for example, I tallied up how much a 3-day stay in the PICU would cost vs. a 6 month supply of Synagis. (way more, obviously.) It's going to be a tougher sell with breastfeeding, but perhaps you can throw in some good stats on the percent reduction in ear infections with BF, and project out how much that would cost alone on pediatrician office visits and antibiotics over the course of 1-2 years.

The other route is to gather ALL of the relevant documentation on the superiority of breastmilk and the AAP and WHO recommendations for BF. I'm an RN, but before I came to work at this place, the person who wrote the coverage guidelines (I write them now) was a pharmacist. Before that, I don't know that the author had any healthcare background at all.

Insurance companies like it when you can show them either that you're going to save them money, or they're really not living up to best practice guidelines. The other thing you can try is doing a google search on "coverage guidelines" for their competitors to see if anyone else covers such things. One of the major ones (Aetna or Cigna, maybe?) will cover breast pump rentals for a limited time.

It sucks, and I've already fought to write a policy to cover breast pump rentals as DME and lost. I am too much of a peon/cog to make a difference, too.

Good luck- I hope that helps some!
post #3 of 5
Hey!

We're in Raleigh and we've seen all of the same folks for help.

Who is your insurer? Blue Cross covered everything for us, except for the breast pump rental. I paid out of pocket for that, for 8 months. The cheapest rental I found was from a LLL leader in Chapel Hill.

Oh yeah, they didn't cover the domperidone, of course, or my visit to the craniosacral therapist (we saw Laurel Wilkins).

When you see Mary Rose T. up at UNC, she typically codes the visit so that insurance will cover most of it. My insurance also covered my dysphagia clinic visits... at 100%, actually, because my baby was so young.

Feel free to PM me... I'd be happy to invite you over and help in any way I can... or just commiserate (I'm in East Raleigh). Have you been to any LLL meetings? I am friends with most of the area leaders and they may be able to give you some more help or suggestions on paying for stuff.

And as far as it costing more than formula... that was true for us... until my son ended up with food allergies and being put on Neocate, which costs $400+ per month. Which insurance also doesn't cover. (He comfort nurses, but my supply went to heck after I discontinued the domperidone, and I couldnt' get it back up again.)

So, just keep that in mind... if you can BF him, his risk of allergies is lower, his lifetime cost of illness is likely to be lower, and you often don't know you have a kid who's allergic to regular formula until you've already tanked your milk supply!
post #4 of 5
Medela has some good info on appealing to your insurance companies. Go to this page and type in insurance in the search box:

http://www.medela.com/NewFiles/search/query.asp

As far as on a "macro" society wide scale, yeah it's extremely frustrating. I wonder if everyone who worked for a large company , state or federal govt would call the customer service line during open enrollment, and ask if the insurance company covered bfing related expenses, if that would make a difference : Maybe not for that next cycle, but if enough people made a big enough perceived demand, maybe it would made a difference.
post #5 of 5
Sorry, I don't have advice either, just commiseration. It would be really great if it were not only covered, but automatically covered, rather than a mama who's already working her butt off to make bfing work having to make tons of phone calls/write letters. When I tried to get pump rental covered for eping the ins person told me the script would have to be for ME, not the baby. Um, yeah, that's really likely that I can get my dr to write that, and then they'd turn it down anyway
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