Help with BCBS MA appeals process

Any help would be appreciated. Thank you in advance.

I started seeing a hand therapist and just had to purchase a set of silver ring splits (https://www.silverringsplint.com/). After calling insurance a bunch of times, I was under the impression that it would be covered, but the last time I called I really pushed for specifics and was informed that the allowable payment amount for code L3933 is $34 and since they consider the company out of network I would get an estimated ~$13 reimbursement per splint. Each of the ones I need cost $112 so that's a joke.

I'm planning to file an appeal requesting 1) a network waiver so it can be considered in-network since there are no out of network options 2) for my out of pocket cost to be capped at 20% (which is their in-network coinsurance for durable medical equipment). I have 2 letters of medical necessity.

What I'm struggling with is what order to do things in. I haven't submitted the claim yet, and the manager I talked to said that I could file the appeal without filing the claim (i.e. before I purchased the splints). I did end up buying them anyway because I really need them and couldn't wait. She also said I could file claim and appeal forms at the same time if needed. I reached out to my HR and they said the insurance broker suggested having my doctor file the appeal form on my behalf – I will definitely ask and see if she'll do it because from googling it looks like I can only file 2 appeals per claim so I want to have maximum chances of success.

So…. file the claim and appeal at the same time? Wait to file the claim until after the appeal is processed? Is there a preferred order of operations and has anyone attempted to do this before?

submitted by /u/electric_apathy
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