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Arguments for Getting Insurance to Cover Advanced Bionics’ Neptune™

December 5th, 2011 by | Tags: , | 6 Comments »

 Andrea P., a mom of a child with bilateral Advanced Bionics cochlear implant recipient is very excited about the newly FDA approved  Neptune™ sound processor; however, she will need to battle with the medical insurance to get them to cover the cost of the sound processor.  She was generous to write a post with advice on arguments for getting medical insurance to cover the new sound processor.

First, let me say “Thank You” for allowing me to be a guest blogger on this great forum! I know that no one enjoys the insurance battle that often comes with your cochlear implant manufacturer introducing a new processor. We had a struggle to get our five year old Elliott, implanted under a year of age so we’ve been there and done that. This will be our first attempt at asking insurance to cover a new processor or hopefully, processors.

We have questioned ourselves as parents if it’s even worth the fight considering Elliott isn’t a big fan of anything to do with water. He has never been fishing or even on a boat. We have attempted to introduce him to pool activities with LITTLE success. We don’t think it’s because of Elliott’s lack of interest in these things, and we firmly believe he can feel our fear! I am absolutely petrified he will fall into a lake or get splashed by waves while fishing or while on a boat and ruin his processors. He has had his implants since he was seven months old! He doesn’t like being without them, even for a few minutes. What if we lost them in water? What if they got damaged by water and the dry kit couldn’t fix it? He would be devastated to not be able to hear!

He is quite the little social butterfly and has been invited to a few pool parties. He happily gets dressed and we talk about the fact that he will have to remove his processors to go in the water. He’s is always excited until we get there and I remind him he has to take his “ears” off. This almost always leads to a meltdown of Elliott saying, “Mommy, I don’t wanna take my ears off! I need to hear!” which is then followed by my feeling terrible that he can’t enjoy such a fun childhood activity comfortably. For these reasons, we have chosen to enter the insurance battle octagon!

A few facts about Advanced Bionics Neptune™:

It’s the only SWIMMABLE sound processor in the world. Whether you or your child enjoy taking a dip in the pool on a warm day or bonding at baby bath time, Neptune™ delivers hearing during those important moments.

The lightweight Neptune™ processor allows you or your child to hear the world with the comfort and beauty of nothing on the ear. Neptune™ gives you the freedom to choose your wearing style—in your hair, on your arm, under your collar, or in your pocket—without compromising performance.

Built Kid Tough™ for rugged use, Neptune™ is ideal for every age and every lifestyle whether you live in a humid area, love to swim, enjoy sports, connect in the classroom, or travel across the globe. Neptune™ carries an IP68 rating that offers maximum protection against solid particles and various forms of moisture, which means that you can hear your best in all weather, all sports, and all terrain.

To ensure you hear your best all of the time, Neptune™ is compatible with ClearVoice™, HiRes Fidelity 120™, and AutoSound™. ***While the Harmony, AB’s current BTE processor, is compatible with these strategies, the previous body worn processor, the PSP, is not. For those individuals seeking an off the ear option, the Neptune is the only processor to be compatible with these new strategies.***

Here is a sample of the letter we plan on submitting to insurance to ask for approval of the Neptune™. Feel free to use it in its entirety or just use parts, whatever you find most helpful!

***Note, some current Harmony users are seeking a possible “upgrade” to the Neptune™ instead of asking insurance to cover a complete new pair. I don’t understand how this would work, but I have one piece of advice when it comes to this. I was told to use the word “replacement” instead of “upgrade.”  Replacement brings attention to the above bullet points that are not offered by the current Harmony processor. It’s worth a shot right???***

To Whom It May Concern:

Elliott (child’s name) is a five year old child (child’s age) with bilateral profound deafness. Elliott received his first cochlear implant at the age of 7 months. He received his second cochlear implant at the age 9 months. He has done exceptionally well with the constant wear and use of these devices and currently meets or exceeds all milestones and language / auditory developments that are appropriate for his current age. The purpose of this letter is to request that health benefits be made available for Elliott to receive a new processor(s) that will be available for purchase in the near future. The new processor(s) called the “Neptune™” will allow Elliott to have 100% access to his “hearing” in what would otherwise be considered “un-safe” situations for him to wear his current processors.  The Neptune™ will allow Elliott to hear while bathing, swimming, or while near a body of water, etc. as the Neptune™ is 100% waterproof.

Elliott’s hearing loss was identified at birth and confirmed at approximately three months of age. He receives significant benefit from the constant wearing and use of his cochlear implants. Elliott has benefited greatly from his ability to have early implantation (thanks to the early approval from this insurance provider / company) and had a minimized period of auditory deprivation. Cochlear implants are to be worn during all waking hours of the day and should only be removed when Elliott bathes, swims, or goes near any type of water due to the current processors inability to get wet. The Neptune™ would allow Elliott to be in these types of “water-friendly” situations without safety concerns for him or the processor.

Elliott would be able to have a more independent life as he would be able to bathe himself (something he is currently unable to do for fear he would not be able to hear if there was an emergency.) Elliott would be able to have a better quality of life as it pertains to social activities. He has expressed interest in swimming lessons and other pool type activities, but is currently unable to participate due to his lack of communication abilities. Again, his current processors are not waterproof while the Neptune™ would open up this previously unavailable life to him.

Elliott would also be able to go near bodies of water such as lakes, the ocean, ponds, etc. with out the potential for the cochlear implant processor to get damaged by getting wet. Elliott is not allowed to currently be around bodies of water without his processors on. This represents a huge safety concern for us if he were to accidentally fall in. The safety concern for Elliott to have access to hearing far outweighs our concern for the processor getting wet. This being said, he misses out on a lot of quality of life activities that other children his age are able to do. He is currently not allowed to go swimming, fishing or on any field trips that would place him near water. He would have access to these new experiences with your approval of the Neptune™, a 100% waterproof cochlear implant processor.

A cochlear implant is the only medical treatment available for Elliott’s type of deafness. He receives no benefit from hearing aides. A cochlear implant is an auditory prosthesis which is surgically implanted into the cochlea and positioned behind the ear. A transmitter is placed over the receiver on the outside of the skin and connected to a miniature computer called a speech processor. This processor receives sound through a microphone and codes them into electrical signals and transmits them into the internal receiver which then stimulates the hearing nerve. The brain interprets these as sounds. Following cochlear implantation, children are able to hear conversation and environment sounds, develop better speech, and in many cases, understand speech without lip reading.  Elliott has become so accustomed to the great benefit he receives from the use of his cochlear implants that he is very uneasy to be with them for even short periods of time.

Elliott was also diagnosed with Usher Syndrome when he was approximately 18 months of age. Usher syndrome is a genetic condition that causes hearing and vision loss in those affected by it. Elliott receives routine screening and evaluations for vision issues which have not presented at this point. Were these vision issues to present themselves with rapid progression Elliott would need the Neptune™ immediately. This is due to safety concerns with a compromised field of vision while in what would then be considered “un-safe” situations such as bathing, swimming, getting caught in inclement weather, etc. It would be detrimental for Elliott to be without the sense of sight or the sense of hearing in the above mentioned situations. The Neptune™ would again, give a sense of independence which Elliott doesn’t have available with his current processors.

Cochlear implant processors worn on the ear may lead to “skin-breakdown” over time. Skin breakdown occurs when the constant wear of a device irritates the skin to the point that it becomes compromised and unable to support an ear level processor for some time. The Neptune™ also addresses this concern as it has an “off-the-ear” wearing option which allows the skin on the ear to essentially “take a break” and restore any damage that may be occurring.  Should skin breakdown ever occur, Elliott would need a “backup” processor until the skin was healed. Again, his current processors can only be worn on the ear making the Neptune™ an immediate necessity to continue the (hearing) quality of life he is accustomed to.

For the many reasons listed above, I ask you to please make health benefits available for Elliott to receive the Advanced Bionics Neptune™ processor(s) when they are available. Safety is the number one concern with an impaired child and this device allows independence, enjoyment of water-based activities and previously unheard of safety for Elliott around water, which would otherwise be an “un-safe” environment for him.

Thank you for your consideration and please contact me with any questions or concerns you may have.

6 Comments

Howard Samuels

December 6, 2011 at 12:13 am

Andrea, you’ve written a very compelling letter to the insurance company. May I suggest that you also ask Elliott’s audiologist and surgeon to write ‘letters of medical necessity?’ Those letters, like yours, should focus on the safety and quality of life enhancements that would not otherwise be achievable without the Neptune processors. Please keep us posted!

December 6, 2011 at 4:38 am

Very well done. You have done an excellent job.

December 7, 2011 at 5:16 pm

Great article Andrea.. working with insurance companies is a nightmare.. I’m a Cochlear Implant patient (1987) and I’ve had my brawls with them over the years in both initial surgery and then all the upgrades and what have you. So far so good but it’s getting harder each time.
I would like to add (and remove this segment.. I’m not a spammer) that I wrote a book called “Hear the Sunshine” that deals with the human issues and some touching base about insurance. its on Amazon.com under my name and title. The book (print and ebook) is intended to give parents a bird’s eye view of hearing loss.
Thanks again for the article.. it’s great.
Chas Wells
Georgia USA

Andrea Patton

December 13, 2011 at 3:16 pm

Thanks everyone! Howard, Elliott’s Audiologist and ENT surgeon will sign off on a letter that they will draft and sign also through Children’s Memorial Chicago (where Elliott received his implants.)

I promise to keep everyone updated as well. Not much will be happening until after the Holidays, but we plan to get everything in motion come January 2nd!!!

May 4, 2012 at 4:50 am

[...] PrintAndrea Patton, who wrote an article several months ago about acquiring insurance approval for the Ne…, finally got insurance approval recently and not only got the Neptune Sound Processors for her son, but also ClearVoice, a new MAPping strategy.  She shares her and her son’s experience in using ClearVoice and the Neptune Sound Processors. [...]

Yanela M

March 29, 2013 at 2:14 pm

My child loves the water and is unable to hear when she is swimming. The Neptune would be a life saving and social advantage for my daughter but the health insurance would not pay for the Neptune