Fourteen weeks. That's how long this took. I'm writing it all down because I could not find this anywhere when I was in it, and if one person copies this and skips even four of those weeks it was worth typing.
Background: baby's six months, I'm in Tucson, back at work since April. I saw an IBCLC twice. Once at three weeks when my daughter wasn't transferring, once at six weeks for a pumping plan before I went back. $300 each. She's cash-pay. Most of them are, on purpose, which I did not understand at the time. She gave me a superbill.
The ACA says lactation support and counseling is preventive care. Zero cost share. No deductible. It's not a nice thing my plan does, it's required.
Round 1, denied. Submitted February 12. Denied March 3. Reason code 242, "services not provided by network/primary care providers." So: out of network, eat it.
The phone call that changed everything. I called Cigna and said: fine, give me the name of an in-network IBCLC within 30 miles of my zip code. Not a list of hospitals. A name.
She gave me four. I called all four. One was a hospital lab. A LAB! Two were OB practices where the front desk had never heard the word IBCLC and one of them offered to transfer me to billing. The fourth was a disconnected number. I wrote down all four names, the date, the time, and what each one said, verbatim, in a Google Doc. That doc is the reason I got paid.
Round 2, the superbill was wrong. My IBCLC's original superbill had only S9443 on it, a lactation class code, and Cigna's rep literally said "that's educational, that's not a covered medical service." She reissued it with diagnosis code Z39.1 (encounter for care and examination of lactating mother) and CPT 99404 for the counseling. Denied again March 20, but for a different reason, and I decided to read that as progress.
Round 3, the appeal. This is what worked. I used the NWLC Breastfeeding Toolkit template letter, which is free and which I wish somebody had put in my hospital discharge folder. Three things went in it:
1. I requested a gap exception (some plans call it a network exception). If there's no in-network provider who can actually deliver the covered service, they cover out-of-network at the in-network rate.
2. I cited the tri-agency FAQ, Part 54, which says in plain language that if a plan has no in-network provider who can provide lactation counseling, it must cover an out-of-network one with no cost sharing. Not at a discount. No cost sharing.
3. The Google Doc. All four names, dates, times, and the sentence "a lab" appearing in a document I sent to my insurance company.
Filed April 6. Paid May 22. $600, all of it, no cost share.
Nothing about this was clever. I was not smart, I was just annoying for fourteen weeks in a row while being sleep deprived and pumping in a supply closet. The denial is the opening offer. That's the whole trick. They deny because most people stop, and I have to assume it works, because I nearly stopped twice.
Marisol, I want to turn this into a real thing on the site. A page with the codes, the FAQ Part 54 language, the gap exception script, the NWLC template, and your timeline. Not an article about how insurance is hard. The actual sentences. If you're okay with me quoting the "one was a lab" part I'd like to, because that detail does more work than any paragraph I could write!
Two questions, because I want to build the version that generalizes:
What was the denial code on the letter, exactly as printed? Camille's story is making me think the codes are...
Quote whatever you want. It was a lab. I want it on a billboard.
Code was PR-242, printed just like that, top right of the EOB in gray six-point type next to about nine other numbers, none of which are explained anywhere on the page. You have to know that PR means patient responsibility, which nobody does, because why would you.
And your second question is the actually good one. Of the fourteen weeks, I did maybe six hours of work. Total. Two phone calls, four calls to their fake providers, one document, one letter, one trip to the post office. Everything...
Datapoint from the lucky end, and then the catch, because I don't want to be the annoying person who says "just use X."
The Lactation Network matched me in about four days. Filled out a form, they checked my plan, came back with three IBCLCs who'd come to my house, and I never saw a bill. Not a discounted bill. No bill! Six visits available. It felt like being handed something that belonged to someone else.
The catch, which I only found out because my sister-in-law tried it after I recommended it: it depends entirely on your plan AND on whether they...
IBCLC, and here's the view from behind the superbill, because the cash-pay thing looks like greed from the outside and it isn't.
I'm cash-pay. Not because I want to be. I tried credentialing with three insurers. Two never responded past the first form. The third offered me $52 for a visit that runs ninety minutes and includes two follow-ups by text over the next week. I can't run a practice on that, so I charge $250 and give everyone a superbill and help them fight. That's the whole story, and it's most of us.
On the codes, since Marisol did the hard...
Sorry to jump straight in with questions but I am literally in the middle of this and I have a UnitedHealthcare denial letter sitting on my counter that I've been avoiding for nine days because I didn't know what to do with it.
Mine says "not a covered benefit." That's different from yours, and I couldn't figure out if it's worse or if it's just different words for the same brush-off. $275, one visit, at four weeks, and I only went because my daughter wasn't taking a bottle and everyone here told me to get someone in person. She was worth...
None of those are dumb, and "not a covered benefit" is actually the easier denial to beat, so put the letter back on the counter and stop being scared of it.
Here's why: lactation support IS a covered benefit, by federal law, on any non-grandfathered plan. So that denial is just wrong on its face. Mine was slipperier. They conceded it was covered and hid behind network. Yours is a flat statement that can be contradicted with one FAQ citation.
Answers in order. Paper AND online, because I trust neither, and I sent the paper copy certified mail for $8.15. Best money...