Category Archives: DMPS

Insurance – “Medical Necessity” Requirement Part 2

Services:  What does the requirement of  meeting “Medical Necessity” mean? 

What it does not mean is what your doctor thinks is beneficial or necessary.  No, the insurance company decides if recommendations meet community standards which are encompassed in the field of traditional medicine or medical literature reviewed by peers only.

If you see the doctor for a condition or illness that does not include a primary diagnoses, the service cannot be billed at a level that meets coding requirements and will be denied.

Conditions such as yeast infections, depression, anxiety, psychiatric codes, heavy metal burden, multiple chemical sensitivity, erectile dysfunction and many others are not primary diagnoses codes.  Irritable Bowel Syndrome is a primary code (criteria must be met for this as with diarrhea and constipation.)  Gas and bloat are not primary.

Some patients arrive at the doctors office with a short list, wanting only a specific condition addressed.  When this happens, it may automatically set the course for denial by the insurance company.  The insurance company wants to see primary diagnoses codes which are define by a coding standard.  Requirement for correct billing is an appropriate ICD-9 code or billing code and a primary CPT code.  

Uncovered codes are patient responsibility if waiver is signed.  Before you leave the clinic with a laboratory test, we will provide you with the cost of the test and the extent of what we believe your insurance will pay.  That amount will be collected at the time of service.   We cannot guarantee your benefit amount because your insurance will not guarantee the information received when we call and verify benefits.  They state and our business agreement states that you solely are responsible for bill regardless of your insurance coverage.

Sample Profiles (list not complete for covered and uncovered tests):

Pesticide Panels:   You must provide a payment for the total billed to the laboratory.  We can then bill your insurance company, later refunding you if coverage is accomplished. 

Amino Acid Assays, Nutritional Based Assays-most insurance companies do not pay these items, however, through an agreement with the laboratory, we can accomplish quality assays for amino acid serum, RBC mineral, organic acid and fatty acid profile for a very low cost.

Genetic Testing-.While this is not a covered expense at this time, there is talk that it may be in the future.  You should consider, if that benefit becomes available, the consequences your genetics may have on life insurance, for example.  

Comprehensive Detoxification Panel:  Portions of this tests are not covered by insurance, therefore, unbilled portions are paid to the patient.  We notify you what we believe your responsibility will be.

DMPS Chelation Therapy and Metals Challenge Test-Does not meet medical necessity and is therefore paid by the patient.  See next segment.

EDTA Chelation Therapy and Metals Challenge Test-We use this therapy for reducing specific heavy metal burden.  Because the conditions we treat are due to chronic exposure, only on rare occasions does insurance ever pay.  Payment is always due date of service.  Toxicity is defined by blood test only and is rarely seen in patients with acquired body burden.   The appropriate test in this case usually will not qualify you to meet medical necessity.  Payment in full is required by the patient.

Environmental Pollutants-We will not bill for this service as most of it is not covered by insurance, therefore, paid in full by the patient.

Food & Inhalant Testing-covered if qualified.  Qualifying a patient includes ages under four, autoimmune disease and chronic skin conditions such as eczema or psoriasis where the doctor believes skin testing may worsen the condition, chronic use of antihistamines without benefit and steroid use.

Hair Analysis-We will not bill for this service as  it is not covered by insurance, therefore, paid in full by the patient.

Vitamin Mineral IV’s-generally not covered and PPO insurances requires that you provide documentation after the service is performed to see if it meets medical necessity.  Therefore, we require payment upfront with a waiver.  In almost every case, insurance does not cover. 

Nutritional Consults by Certified Nutritionist-typically uncovered. 

Other tests such as the ION and TRIAD panel by Metametrix is payable in advance.  We will then bill your insurance company and refund any portions paid.  

Stool Testing:  Payable if criteria is met.

Center for Environmental Medicine

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Heavy Metal Burden-Cadmium, Lead, Mercury Plus More

In the toxic environment we live it, it is hard to imagine one being able to escape the potential dangers that threaten us in our air, water and food.  Some believe, as I do, that the health of this nation, evidenced by the escalation of heart disease and chronic acquired diseases, is in direct relationship to the accumulation of the toxins within.  High levels of metals, drugs, and manmade compounds can be found in our environment.
 We hear about the effects of global warming more than we hear about how toxins are dismantling this nation of its richest resource–health.  As stewards of this earth and our bodies, we need to understand the problem and do our part to protect our families, community and self.  We aren’t hopeless or helpless in this age of information unless we choose to be. 

 Heavy metal burden is the unintended consequence of industry worldwide dating back to the Industrial Revolution in the 1700’s.  The economy that was created unquestionably changed the world…and it is still changing our world today.  The cost of healthcare continues to rise and some believe that the collection of heavy metal entities in the body contributes to acute and chronic disease, primary introduced into the body by oral or inhalation means.  Cadmium is the most toxic element to man, then lead, then mercury.   Toxins that are manmade chemicals contribute as well.  Little is considered as people wash with scrubs or work with unprotected hands in harsh chemicals.

The economy of healthcare is found in the treatment of disease.  While an enormous amount of money annually goes to research, the title of drugs is at the top of the lists.  One thing for sure, there is a drug for almost everything.  Illness is sometimes considered a synonym for disease or sometimes viewed as the subjective perception of the patient or an objectively defined disease.  If the objectively defined disease is illusive, then the problem exists only in the mind of the patient. Or does it?  

Environmental doctors and those interested in prevention of disease take a different look at the disease model. First, they consider the patient might be right!  Their symptoms might actually be an underlying cause even thought the cause may be illusive and unrelated to emotional or mental illness.   You don’t have to be a doctor or struck with illness to share wisdom.  It is easier and less expensive to prevent disease than to treat it. 

The alternative doctor looks at the body and sees it wondrously made. Food and nourishment is required to fuel and maintain the machine.  The cleaner sources the food comes from, and the more nutritious the source, the better.   If the body is unable to function properly because of enzyme and nutritional deficiencies, should you add a drug to make the process happen or inhibit another process to provide an artificial balance?  In alternative medicine, the practitioner strives to restore the balance.  Removing a toxin is preferred to adding a drug and reasonable nutritional support including a healthy diet. 

One area of alternative medicine many patients have benefited is detoxification programs including those specifically designed to remove xenobiotics (manmade chemicals including plastics and pesticides) and chelation for heavy metal burden.  A healthy BMI (body mass index) is important because toxins store in fat.  If your attitude reflects little dedication for long term effects of healthy living, then you need read no further.  If you understand investing in your health has long term rewards, then you should consult a trained practitioner in chelation to get the best care.

 For example, some professionals use blood tests but results reflect recent exposures and typically not chronic exposures. Others use hair analysis which typically reflect chronic exposure but not body stores of toxic metals.  Fecal tests can be influenced by dietary and metabolic factors.  Challenge tests may fail to produce an expected response in glutathione deficient patients, provide the best results for elevated and very elevated levels.  The challenge test, with the preferred chelator,  is the preferred test.  Often multiple toxic metals are present and increase the duration of the chelation processEach additional toxic metal lowers the toxic threshold for every other metal resulting over time in dysfunction of multiple organs and tissues, impaired chemical detoxification, excessive free-radical formation, and chronic conditions such as chronic fatigue syndrome and fibromyalgia.  Also, increased oxidative stress, related to elevated heavy metals may precondition you for heart disease.  

The impact of how heavy metal burden affects a person depends on their sensitivity. Type O blood patients seem to provide few symptoms and these are the patients who take the least care of themselves because they “feel fine”.  “Feeling fine” does not necessarily reflect the truth which is why health checkups are important.  Areas of concern may be when you see elevations of cholesterol, dysfunction of blood sugar, mental confusion and fatigue.  For example, trace mineral depletion is caused by disruption of transport by heavy metals competing for receptor sites on transport proteins and metallothioneins and by binding sulhydryl groups on many enzymes.  This process may be so gradual, you may fail to recognize the onset of persistent fatigue, decreased mental acuity, or increased issues with metabolism, yet your doctor may not know how to test for these or why they might be important.  In contrast, the type A blood patient is very sensitive and notes many more symptoms because they tend to be more sensitive to their environment.

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