STATEN ISLAND — Michael Novick, a Staten Island accountant, had been fighting with Emblem Health, a major medical insurer, for more than a year when he reached out to PIX11 News for help.
Michael had his lower right leg amputated, due to diabetes, in December 2018. After spending weeks at the Staten Island University Hospital North's acute rehab unit, the physical therapists he worked with said he should be walking again within six months.
First, he had to be fitted for a prosthetic leg from the knee down. That required approval from his insurance company, Emblem Health.
Incredibly, the claim he filed was rejected.
"We asked your doctor for the records needed to assess for medical necessity," the rejection letter said. "We did not receive what is needed. In order to approve a prosthetic lag, certain points must be met. We do not know the following details: 1. If you want to walk."
Want to walk? Why else would he have been going through rigorous physical therapy for months?
Michael's doctor, Dr. Robert Fulop, said the insurance company's reason for denial "is absurd". He said he records made it clear that was the objective of Michael's treatment.
Michael, who was shocked by the denial, wrote a three page letter titled in bold print, all capitals, "I WANT TO WALK."
He listed many reasons for wanting to walk, including the 30 steps in his house, the need to travel for his job and the desire to lift up and hold his young niece and nephew.
He resubmitted the claim for the prosthetic and couldn't believe it when he got back another denial. The reason: "We have determined that the services (including the prosthetic limb) are not medically necessary".
"From a medical point of view, I can't ever imagine how somebody would question the necessity to have a prosthetic," said Dr. Fulop. "Without one, this gentleman is an invalid."
Novick was angry.
"What is it going to take for these people to see what is common sense?".
After he reached out to PIX11 News for help, we investigated his case and then contacted Emblem Health. Shortly thereafter, a company vice president contacted Michael.
"She got my file the previous night. She's reading my story and she's speechless as to what I've been going through," Novick said.
The company did its own investigation and quickly determined that it's subcontractor in charge of reviewing claims for prosthetics had made some obvious mistakes. The decision was reversed and his claim was approved.
It's taken almost 8 months for him to finally get a properly fitting prosthetic.
Michael Novick is now learning to walk again. It is frustrating but there are some major victories.
"Two and a half weeks ago, I climbed the steps in my synagogue for the first time in two and a half years."
PIX11 News is happy to have helped make it happen.
If you've got a story for Arnold Diaz to investigate, send an email to Arnold.Diaz@pix11.com or call at 212-210-2473.