What is the name of your state (only U.S. law)? Texas
UPDATE: Seeking OPINION only not true legal interpretation as I will not construe as such obviously. I should have made that clearer apparently.
I believe my company and insurance are both misinterpreting the Texas Code & my Insurance Summary Plan. In your opinion would all FOUR disorders listed below in 1-4 under diagnosis need to be met or ONE out of the disorders/diseases should be met for coverage? All four being met before covered seems crazy to me, but I would like other's opinions as I am hardly an expert. I have been denied multiple times for coverage even though my daughter's newborn DNA screen reflected this issue, our pediatrician has provided the medical necessity letter, etc. & am at the very last stage of requesting an external review in my appeal. I would like this applied to deductible since I have paid $2k out of pocket and have a high deductible plan, but if I am the one reading this incorrectly then I should probably just drop this altogether.
Side note: As of mid-year this year my company switched over to self-funded insurance coverage which is governed by ERISA and not Texas Insurance Code. I am seeking coverage under both the prior plan (governed by Texas) and now under the self-funded plan as it overlaps (ERISA). I cannot find anything published from ERISA on this topic, but please comment if you have knowledge of anything. Thanks in advance of any and all replies!
TEXAS INSURANCE CODE
SUBCHAPTER B. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS
Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS. (a) A health benefit plan must provide coverage as provided by this chapter for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:
(1) immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins;
(2) severe food protein-induced enterocolitis syndrome;
(3) eosinophilic disorders, as evidenced by the results of a biopsy; and
(4) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.
(b) Subject to Subsection (c), the coverage required under Subsection (a) is required if the treating physician has issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Subsection (a). The coverage must include coverage of any medically necessary services associated with the administration of the formula.
(c) A health benefit plan must provide the coverage described by Subsection (a) on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan, and to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
MY CURRENT HEALTHCARE SUMMARY PLAN
Amino Acid-Based Elemental Formulas
Benefits are provided for amino acid-based elemental formulas, regardless of the formula
delivery method, that are used for the diagnosis and treatment of:
■ Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food
proteins.
■ Severe food protein-induced enterocolitis syndrome.
■ Eosinophilic disorders, as evidenced by the results of a biopsy.
■ Impaired absorption of nutrients caused by disorders affecting the absorptive surface,
functional length and motility of the gastrointestinal tract.
Benefits will also be provided for any medically necessary services associated with the
administration of the formula.
UPDATE: Seeking OPINION only not true legal interpretation as I will not construe as such obviously. I should have made that clearer apparently.
I believe my company and insurance are both misinterpreting the Texas Code & my Insurance Summary Plan. In your opinion would all FOUR disorders listed below in 1-4 under diagnosis need to be met or ONE out of the disorders/diseases should be met for coverage? All four being met before covered seems crazy to me, but I would like other's opinions as I am hardly an expert. I have been denied multiple times for coverage even though my daughter's newborn DNA screen reflected this issue, our pediatrician has provided the medical necessity letter, etc. & am at the very last stage of requesting an external review in my appeal. I would like this applied to deductible since I have paid $2k out of pocket and have a high deductible plan, but if I am the one reading this incorrectly then I should probably just drop this altogether.
Side note: As of mid-year this year my company switched over to self-funded insurance coverage which is governed by ERISA and not Texas Insurance Code. I am seeking coverage under both the prior plan (governed by Texas) and now under the self-funded plan as it overlaps (ERISA). I cannot find anything published from ERISA on this topic, but please comment if you have knowledge of anything. Thanks in advance of any and all replies!
TEXAS INSURANCE CODE
SUBCHAPTER B. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS
Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL FORMULAS. (a) A health benefit plan must provide coverage as provided by this chapter for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:
(1) immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins;
(2) severe food protein-induced enterocolitis syndrome;
(3) eosinophilic disorders, as evidenced by the results of a biopsy; and
(4) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.
(b) Subject to Subsection (c), the coverage required under Subsection (a) is required if the treating physician has issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Subsection (a). The coverage must include coverage of any medically necessary services associated with the administration of the formula.
(c) A health benefit plan must provide the coverage described by Subsection (a) on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan, and to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.
Added by Acts 2009, 81st Leg., R.S., Ch. 1129 (H.B. 2000), Sec. 1, eff. September 1, 2009.
MY CURRENT HEALTHCARE SUMMARY PLAN
Amino Acid-Based Elemental Formulas
Benefits are provided for amino acid-based elemental formulas, regardless of the formula
delivery method, that are used for the diagnosis and treatment of:
■ Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food
proteins.
■ Severe food protein-induced enterocolitis syndrome.
■ Eosinophilic disorders, as evidenced by the results of a biopsy.
■ Impaired absorption of nutrients caused by disorders affecting the absorptive surface,
functional length and motility of the gastrointestinal tract.
Benefits will also be provided for any medically necessary services associated with the
administration of the formula.
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