Enterolab Codes - Insurance Stuff

[Izak's Mom]

Thought I'd share some info I got from Enterolab over the phone the other day when I called to find out what the deal was with insurance:

Below are the codes for the Gluten Sensitivity Stool and Gene Panel Complete. Once you have the test, Enterolab provides you with a coded invoice to submit to your insurance company. To find out if these tests are covered by your insurance, call up your insurance provider's customer service and read them these codes - they'll be able to tell you if they're covered or not. I haven't yet gotten in touch with my provider, but I'm hoping that some or all of these will be eligible!

CPT codes:

83520

82710

83898

83890

83894

83896

83912

[Izak's Mom]

Hmm...so I called my insurance and it seems since Enterolab isn't a BC/BS PPO provider, the tests aren't fully covered (although they would be if Enterolab were in their network).

Sooo...anyone know an alternative to Enterolab that IS in the BS/BC network? Help!

[dionnek]

I have BC/BS of GA and I called and they said it would be covered. I haven't ordered yet. Does anyone know what tests I would need to order to see if my (nonsymptomatic) 22 month old daughter has the gene? I have just been dx, and want to see if she might possibly ever get celiac, so was thinking of just ordering the gene test from Enterolab. Any thoughts?

[oceangirl]

I have BC/BS of GA and I called and they said it would be covered. I haven't ordered yet. Does anyone know what tests I would need to order to see if my (nonsymptomatic) 22 month old daughter has the gene? I have just been dx, and want to see if she might possibly ever get celiac, so was thinking of just ordering the gene test from Enterolab. Any thoughts?

Izak's Mom

Thank you for providing those codes.

lisa

[jayhawkmom]

Our insurance company will cover those specific tests, provided ONLY that they are done in one of their providers. So, for us... Enterolab would cost us exactly what they are charging. But, if there were an "in network" lab that would run those specific tests, they'd be covered.

[Izak's Mom]

Our insurance company will cover those specific tests, provided ONLY that they are done in one of their providers. So, for us... Enterolab would cost us exactly what they are charging. But, if there were an "in network" lab that would run those specific tests, they'd be covered.

That's the boat I'm in. I emailed Enterolab about it - here's what I asked & what they said:

My Question: I can't afford the full panel for my suspected-Celiac son Izak and since you are not a BC/BS PPO provider, my insurance won't cover it (they would 100% if you were in the network) - I know this may not be an appropriate question, but please, do you know of any other companies that do your testing that are BC/BS PPO providers? Can my local hospital perform the same tests? Thank you for any advice!

Response: Dear Elisabeth, I am sorry that this is an inconvenience for you, but there is no other lab right now that can run our tests since Dr. Fine holds the patent on them. Perhaps you could order only the gluten sensitivity stool test for $99, which would at least let you know if you need to take gluten out of Izak's diet. We have had some BCBS carriers cover the cost of our tests, but I do not know how the patients get them to do it. Sometimes having a physician's order helps and telling the insurance company that we are a specialty lab and you cannot get these labs done anywhere else. Please let me know if I can be of further assistance. Sincerely, Phyllis Zermeno, RN, BSN Clinical Manager

So as soon as my son's doc gets back from vacation, I'm going to see if there isn't some way around all this - if he's got a patent on these specific tests and they're the only place that does them, I have to suspect that a little prodding/insisting from a physician (instead of a griping mom) will get better results.

[acousticmom]

So as soon as my son's doc gets back from vacation, I'm going to see if there isn't some way around all this - if he's got a patent on these specific tests and they're the only place that does them, I have to suspect that a little prodding/insisting from a physician (instead of a griping mom) will get better results.

Please keep us posted on your progress!

Carol

[dionnek]

BC/BS of GA will supposedly cover the tests - I just ordered the gene test so I will let you know if they actually do pay out for it. Have you tried Kimball Labs (in Denver)? They do the gene test and blood panel (home kit) and maybe your insurance would be more willing to pay for theirs? I know you can have it sent to your dr's office and have your dr perform the test, so maybe then insurance would pay. Check out their website and call the 800 number - they will give you the CPT codes for you to call your insurance company.

[Sally's Mommy]

BC/BS of GA will supposedly cover the tests - I just ordered the gene test so I will let you know if they actually do pay out for it. Have you tried Kimball Labs (in Denver)? They do the gene test and blood panel (home kit) and maybe your insurance would be more willing to pay for theirs? I know you can have it sent to your dr's office and have your dr perform the test, so maybe then insurance would pay. Check out their website and call the 800 number - they will give you the CPT codes for you to call your insurance company.

I know it depends on which BCBS plan you have, but mine covered my daughter's tests, minus her $200 per year deductible, and minus 20% for going out of network. It wasn't much money back in my pocket, but now we have met our family deductible, so I am going to order my test, which they should cover at 80%.

I got a medical claim form online and filled it out, and I printed out and attached the email I received which had a breakdown of the individual tests. Hope that helps!!!

[Izak's Mom]

I know it depends on which BCBS plan you have, but mine covered my daughter's tests, minus her $200 per year deductible, and minus 20% for going out of network. It wasn't much money back in my pocket, but now we have met our family deductible, so I am going to order my test, which they should cover at 80%.

Sally's Mommy - that's the same that mine will do, but what I'd wind up paying after the deductible, etc. is pretty close to just paying the $369, which is out of my budget range at the moment.

Update - I spoke with my son's ped. and she didn't even hesitate for a second when I asked her to order the tests through Enterolab - she's all for it. (Yay!) So now I just have to wait for them (his ped.) to call Enterolab & find out about the collection procedures (his ped. did say that it might be possible for the lab at the hospital we go to to collect & send a specimen instead of having to wait for the collection kit to arrive) and then it's off to the races...will let you know how it turns out.

I'm kinda curious to see if the tests confirm my own diagnosis, but at this point, even if they don't I'm still going to keep him on the diet. The response has been so clear that I'm just not willing to go back to changing nasty yellow squirt diapers!

[Izak's Mom]

*sigh*

so, here's the latest: seems my son's ped. decided to consult with the hospital ped. GI person, who basically told her that there was no such thing as a reliable stool test ("if there were, i'd be prescribing them") and that we should have had the blood work done before doing the elimination diet. so much for having the enterolab tests covered by my insurance! on the upside, she (my son's ped.) did write out a lab slip for a genetic test, which from what i understand is a blood test & it doesn't matter what you're been eating - if you have the gene, you have it. other than that though, she said i'd basically have to feed him one cracker a day until he had a reaction before we could do the igA tests. which is not even an option for me, at least not now! but i am going to have the genetic test done, just to see the results. although, here's a question - i really don't think he has full blown celiac, but is definitely intolerant of gluten. are those the same gene?

will let you know how the testing goes...i think i'm going to bring him in friday for it.

-e

[Izak's Mom]

So we finally got our genetic (blood) test results (wound up going through Prometheus Lab so insurance would cover it). Izak tested positive for HLA DQ2 (HLA DQA1*05/DQB1*02) and negative for HLA-DQ8. From what I've read online thus far, it appears that celiac is most commonly associated with the DQ2 gene, although my personal opinion is that he's non-celiac gluten-intolerant. Anyway, our ped. referred us to the ped. GI person so we have an appt. in December (apparently there's only ONE ped. GI person in the entire state of NH!) I guess I feel sort of vindicated...I've had him gluten-free since he was 9 months old (he's 15 months now) and the dietary response has been fantastic - it basically 'cured' him (his main sympotm was chronic explosive D), but you know with some family/friends etc. they want to know what the "official" diagnosis is, so now I have a "real" lab test proving I'm not some cuckoo mom watching too many Discovery Health shows (lol - it's true, I love anything surgery, the more intense the better!) Will let you all know how our appt. goes...I'm curious to see what the GI has to say.

[MKMBeau]

Thanks so much for this info. I just recently had a "clear" Endoscopy/Colonoscopy and "iffy" blood tests, (GI resident's words, not mine) but have been seeing an increase in frequency and severity of symptoms over last 9 months (migraines, GI distress, bloating/gas with pain, loose stools, constant going to the bathroom, irregular periods, yeast infections, asthma, allergies, joint pain etc.) and noticed the distress and pain, especially becoming much more accute, so I'm not satisfied and want further testing. I had looked into Enterolab and assumed it would all be out of pocket for me, which was discouraging. I probably do not have Celiac Disease, but something is most definitely not right!

Just to add to the knowledge on the board about Enterolab and BC/BS--- I called my BC/BS (of Massachusetts, through Oregon (hubby's company based in OR) and gave them these codes. They will pay 90% if my GI doctor, who is in-netowrk, orders the tests, 50% if I order direct (which is still something...) With a deductible of $250 I'd end up paying full price anyway, but since I just had the GI procedure I'm going to go ahead with this before the year turns over.

I am so frustrated with feeling terrible and having doctors tell me "Everything looks fine." Clearly, everything is not "fine." I respect my GI doctos and they have been very good so far with my procedures and not making me jump through hoops to have them done, etc. but I'm keeping my fingers crossed that they don't balk when I bring them these tests and ask them to order!

[1974girl]

I think it was Peter who has asked this question before but has anyone had Entrolab tests run that did not show gluten sensitivity? It seems they all come back that way. Heck, maybe we all are but I was just wondering. I have bc/bs and they were wonderful with my regular blood work from their usual lab. They even paid for the gene testing. And they paid for all the family members to be tested. I was worried about that one since the rest of us do not have any symptoms. If you can't afford what you want at Entrolab, then just get the regular blood work. It will give you a good idea. They were great with us.