Although several clinical studies have demonstrated that Botox is an effective treatment for urge incontinence (UI), its use for this is not approved by the U.S. Food and Drug Administration. Using it this way is considered "off-label," but it's not illegal. Doctors can prescribe medications for other than their intended usage. However, unless you have a spinal cord injury or some other neurological disorder resulting in voiding dysfunction, most insurance companies won't cover off-label use of medications, and therefore won't cover Botox for UI.
Because of this, most doctors assume it won't be covered. However, it sometimes pays to do your own research. I figured out that my insurance might cover it for my condition. I was able to find my insurance company's "Position Paper" on Botox. This is their statement of what they will cover and what they won't. In reading it myself, I found that they should cover it. However, it had to be pre-approved.
You can request coverage from your insurance company yourself, but it's better to ask your doctor to help with this. It will carry much more weight with your insurance company coming from a physician. Find all the information you can (studies, position papers, etc.) and share everything with your physician. Ask him or her to send the letter on their medical facility letterhead.
Assume that your initial request will be denied. In other words, start planning any appeals before the initial request letter is sent. Find out what the appeal process is from your insurance company - don't rely on your insurance benefits booklet. Keep records of any correspondence, including email. In my case, the address in the benefits booklet of where to send any appeals was WRONG. Any appeals sent to this address would have been lost or ignored.
Keep copies of everything you submit, and request copies of everything your doctor sends. There's a good possibility that your insurance company will lose it at least once. For my request, my insurance company lost both the initial letter and the appeal. Everything had to be sent twice. What worked best was to fax everything, and then follow up with an email or phone call soon after to make sure they received it.
Another good resource for help with this process is Allergan, one of the makers of Botox. They provide several websites to assist with obtaining Botox:
- Helpful Resources website provides patients with help in writing letters, appeals, etc. I didn't know this at the time, so I had to figure this out for myself.
- Botox Provider Portal is available to assist physicians with help with requesting insurance coverage for their patients.
- Allergan also has a Patient Assistance Program in which they will donate the Botox. However, they won't pay for any procedure or physician charges, only the Botox itself. There are a number of conditions that must be met before they'll provide help. Some of these are listed on the website, and they require you to call to make the request.
It may seem like a lot of work (trust me, it is) but in the end it may be worth it. Remember, you have to do most of the work yourself, and assist your physician as much as possible. I can't stress the following enough:
- Keep copies of everything!
- Be prepared to resubmit your paperwork or ask your physician to do it. It will probably get "lost" at least once.
- Always follow up to make sure the insurance company received your request and that it's being reviewed.
You MUST be your own advocate. No one will do the work for you, especially your physician. Be prepared to hear "No" at least once from your insurance company. And yet, perseverance may pay off with dry days for months!
Published On: September 03, 2008