Patient Reimbursement Guidelines

Insurance is always a big question when it comes to healthcare. Particularly, pectus carinatum and rib-flare are challenging areas to rely on insurance reimbursement given the lack of clarity in the insurance coding system. Today, we’ll walk you through some background on how insurance works, what the status is of compression bracing within the insurance ecosystem, and how to best go about getting insurance to pay  for some or all of the cost of Dakota Brace. 

How Insurance Codes Work

At a high level, insurance companies follow a set of codes by which they categorize the treatments they cover. These go from the very basic to the highly complex. With respect to bracing for pectus carinatum or rib-flare however, there was no dedicated treatment code recognized by insurance until April 1st, 2024. This has traditionally made it difficult to get reliable results and coverage when applying for reimbursement. In general, the code used by patients and providers in the industry was an L-1499 code, which is a “Spinal Orthoses, Not Otherwise Specified.”

As of April 2024, providers are beginning to use a dedicated code, L1320, to bill for the brace. As of May 2024, this code does not have a set reimbursement attached, so the industry is unsure what insurers will reimburse for the brace when using this dedicated code. 

How Insurance Makes Coverage Decisions

When applying for insurance coverage, insurance companies will only cover what they deem “medically necessary.” This is largely dictated by the diagnosis given by a licensed physician—however, it is not always enough to get coverage for the treatment, as it is also dependent on your benefits and the particular insurance company. With respect to pectus carinatum for example, if a physician diagnoses a patient with pectus carinatum and prescribes bracing, an insurance company can still approve or deny based on benefits. One common example we hear is that if the script describes the problem as “cosmetic,” the brace is much less likely to be covered than if the script describes physiological problems like  shortness of breath or pain caused by the pectus carinatum. 

Applying For Insurance Reimbursement

In general, given challenges with no existing treatment code, getting insurance coverage can be tricky from any provider of pectus braces. Especially when factoring in deductibles, it’s more often that not more economic to pay for the brace out of pocket and our financing option to make the payments as manageable as possible. Finally, don’t forget to schedule your free consultation to get money off your order!

At Dakota Brace, we don’t apply for insurance on your behalf. However, we recommend that patients looking to use insurance apply for reimbursement for the brace directly with their insurance company. Here is a good article describing the process of applying for reimbursement from your insurance company. The particular forms and information required depend on your health insurance company, but the general  guidelines are great! You may be able to file this claim online instead of via mail depending on your insurance provider.

Best Practices in Applying for Reimbursement 

When meeting with your doctor and getting a script, ask them to describe any needs related to physical performance (like shortness of breath) or pain (chest pain, trouble sleeping). These are more likely to warrant reimbursement if they are symptoms. The doctor’s script will definitely be needed when submitting for insurance reimbursement.

When referencing Dakota Brace as your provider, include our National Provider Identifier (NPI) as well as our information:

Company Name: Dakota Brace 

NPI: 1518605294 

Phone Number: 575-573-2887 

Address: 205 Main Ave E, West Fargo, ND 58078 

Use your order confirmation as proof of receipt when submitting for reimbursement, so the insurance company knows what you paid for  the brace and what to reimburse. 

As always, reach out to us at success@dakotabrace.com or text/call us at 575-5-PECTUS (575-573-2887) with any questions. We’ll try our best  to get you the information you need to get this life changing product to you!