Help-Insurance refusing to pay for J-tube formula

I just received a call from the company that supplies the formula for my J-tube.  My insurance company will not cover the cost (apprx $1K per month).

Of course - I now have received 2 shipments and I am responsible for the bill.  Please note that my insurance company paid for surgery (J-tube placement), for the pump and medical supplies but will not pay for the formula.  Could someone have told me this earlier?

I called the insurance company and was told that they would not pay for formula because complication was due to weight loss surgery and my benefits did not cover it.  Huh?

I have contacted MD to see if the billing code is the problem or will this even help at this time?

I have also contacted HR - looking for patient advocacy help.

They denied payment of Zofran - which I pay for out of pocket.  What is next?

Any insight from other J-tube users?

Also, now I am afraid to have labs done for fear they will not pay for that - what billing code should be used for this?

Who is your insurer?  Many insurance companies won't pay for things related to a surgery they don't deem "medically necessary", ie plastics. 

HOWEVER, regardless most of them will cover life saving therapies if it is coded correctly.  How long have you had the j-tube in?

Did they cover your surgery or were you self-pay? If you were self-pay some insurances won't pay for complications from procedures they denied. But if that's the case its odd that they paid for your J-tube placement because that was due to a surgical complication as well.

Update:  Based upon my insurance company policy - they do not pay for formula unless you are an infant with a metabolism problem.  Coded "inborn error of metabolism".

I do have to pay for the formula.

I have had the J-tube almost 6 weeks and this is the first time I was notified that insurance did not cover the formula.

If I had been told - I could have bought it directly from Abbott Labs for about $45 a case.  I need about 6 cases a month.  The supplier bills the insurance company a flat rate of $1000 for formula ( I hope the other supplies that I receive are in this total - but that was not what they led me to believe).  I called the supplier and asked to negotiate rate.  I was able to get the Medicare rate of approx $300 a month.

As long as I have the tube - the formula will have to come out of my pocket.

can you return the $1000 supply and order the $45 case.

this stinks for sure. So sorry ! 

There are many people that can have abdominal surgeries that lead to complications needing a G or J tube needing protein feedings.  This past fall I had a bowel obstruction which  my surgeon said could have been a complication of my surgery but may not have been.  Many people in the general population have these same problems.  As a complication of the bowel obstruction, I ended up with perforated colon leading to an illiostomy and G tube.  I was on tube feeds for about 6 weeks in the hospital and 1 month at home.  I don't know what it cost as Medicare paid for the entire thing but I don't see how they could just say a blanket stament of it is only necessary for children.  Adults do have these problems.  What about people with chrohn's disease, cystic fibrosis and other disorders with malabsortion?

Why did they deny Zofran?  I know this is a drug they dont' like to pay for - my doctors had to fight for it but in the long run, it got approved.  Sometimes you have to get your doctors to appeal these denials, it is worth a shot.  The zofran also comes in a few different formulas - I can't get the sublinguals but I can get the pills.

That stinks and I am not by any means good with insurance, it's the worst part of my job in health care. I have had a J-tube for malnutrition and here's a little bit of hopeful information.
First, it is a bit hairy getting a formula that the intestines do not cramp with, since the tube is directly in the gut. I used the highest level protein formula I could get ordered by my doc and eventually just went straight to feeding myself protein shakes.
It was tolerated just fine, was less carbs, more protein and more nutrition for my DS needs.
I feel the key to Jtube feedings are the rate of speed. If you aren't already doing it, I'd suggest getting a pump for 12 hour night feedings rather than gravity feeds, because those were too fast and caused me cramping.