Guest guest Posted July 26, 2000 Report Share Posted July 26, 2000 - I found that there are two things you have to do to get your insurance to pay. One is to present a very compelling picture of your daughter's condition, that she will deteriorate if not treated, etc. etc. The seond is to be a huge pain in the butt. Make phone calls EVERY DAY, keep calling, leaving messages, bugging people. My insurance finally paid up because they were so tired of my annoying them. Letters aren't as effective. Hope this helps - it's unfortunate that you have to resort to these measures to get proper care for your child, but you do. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 26, 2000 Report Share Posted July 26, 2000 Dear I live in SC and we have cigna as insurance carrier. They have paid for Dr. G consult whether in person or over the phone with no problem. We also have medicaid. Every time we have blood work or prescription we ask our local doctor to rewrite the orders and use Kline lab. We have been covered with Insurance as a primary and Medicaid as secondary. Where you successful with ABA coverage? Where are you if I may ask in SC? Mercy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 24, 2002 Report Share Posted January 24, 2002 - You and I have a lot in common. Both dealing with Children's in Seattle and both of us have Regence insurance. I don't understand why that person told you that. May I ask who told you that? The receptionist I talked to told me the same thing, that they don't have any luck with Regence. However, when I talked to Darcy King, the practitioner, I asked her about that statement. She said they haven't ever had Regence pay, however, she wasn't sure anyone had actually appealed their denials. Currently, Regence is denying payment, but I am working on my appeal as we speak. When I was at my initial appt with Darcy, she gave me a letter of medical necessity to send to my insurance company. They promptly sent me my denial letter, but did she give you one? I am very shocked that they would tell you not to even try. ESPECIALLY since when got his helmet on the 17th and I saw Darcy, she told me that Regence finally did pay for a helmet after the third appeal. Did you talk to ? If so, I would take everything she says with a grain of salt and call Darcy direct with any questions. I am in shock that they would tell you that. And this is very recent that Regence finally paid, like a matter of a couple weeks ago! Definitely call Regence. They will tell you that it is denied because it is considered investigational, but this is just part of the process you have to go through. Get some kind of denial in writing before you cast. Kellie, mom of , helmeted 1/17/02, born 1/17/01 Tacoma, WA Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 24, 2002 Report Share Posted January 24, 2002 , My ortho said that my insurance co had never covered a helmet and when it was all said and done they paid for my daughters. It is worth the fight. Perhaps your insurance company has just never butted head with the right person. I was denied at every appeal level by my company. Then I filed a complaint with the State Dept of Health and started an External Review. That is when the complaint got paid. If that had not worked I would have taken my company to small claims court (I had already consulted with an attorney and he told me what I should do since the total amount was small). I think it was worth the fight. I had to be VERY organized and I documented absolutely EVERYTHING. Phone conversations, dr appointments, faxes, letters - you name it, I saved it! Insurance companies count on people deciding that it is easier to pay for it themselves then go through the hassle of fighting. I would highly reccommend fighting - let me know if you need any help or advice. By the way - what was the basis for the denial? Good luck and I think it is worth the fight. Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 24, 2002 Report Share Posted January 24, 2002 Definitely call your insurance company. If they deny it ask for the denial in writing so you can appeal it. Your appealing and winning will help some other parent in the future win their appeal. Definitely worth fighting. We won on our first appeal with MAMSI here in land. It only covered 50 percent under our policy but it's 50 percent less I don't have to pay. Candy, mom to (DOCbanded 10/5/01) --- In Plagiocephaly@y..., " barryandnancys " <barryandnancy@m...> wrote: > We just made our appt. to have Preston's helmet fitted on the 15th of > Feb. The lady I talked to said that I don't even need to try to call > my insurance company (Regence) that they won't cover this no matter > what. My question is should I still try? Has anyone been successful > getting their insurance company to change their mind? It's worth > $1600 but I've had insurance hassles before and they always win in > the end. I've looked at the other insurance info on the web site. > Preston has had plagio since he was born and my insurance says it > will cover congenital abnormalities. Thanks for your advice. > > > mommy to Preston Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 24, 2002 Report Share Posted January 24, 2002 : YES, definitely fight your insurance company til the very end! SO many of our members have been denied & denied and eventually won. $1,600.00 is a ton of money. I'll give you some links to check out in a minute. Good luck. Debbie Abby's mom DOCgrad MI --- In Plagiocephaly@y..., " barryandnancys " <barryandnancy@m...> wrote: > We just made our appt. to have Preston's helmet fitted on the 15th of > Feb. The lady I talked to said that I don't even need to try to call > my insurance company (Regence) that they won't cover this no matter > what. My question is should I still try? Has anyone been successful > getting their insurance company to change their mind? It's worth > $1600 but I've had insurance hassles before and they always win in > the end. I've looked at the other insurance info on the web site. > Preston has had plagio since he was born and my insurance says it > will cover congenital abnormalities. Thanks for your advice. > > > mommy to Preston Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 5, 2002 Report Share Posted May 5, 2002 Hi Amy, You can start treatment before you are approved but keep in mind that if you are denied,you will not be reimbursed. If you would be willing to pay for it yourself if you do get denied you might as well go ahead and start treatment. Which doctor told you it is basically for cosmetic reasons????? If a normal pediatrician, ask to go to a neurologist or cranialfacial surgeon. If you are denied for cosmetic reson, you must have that medically necessary letter!!!! Do you have a Cranial technologies near you? I have heard somewhere that you can go there for a free evaluation. Maybe they could provide a letter of medical necessity. I am not sure but maybe someone here will know if you can get one that way! Good Luck with whatever you choose to do but I would demand second opinion to get that letter if your doctor won't.~ w/la n Plagiocephaly@y..., " holcombamy " <holcombamy@y...> wrote: > My son (5 months tommorow) will be casted and fitted for a > locally made helmet this coming Thursday. The insurance people at > the hospital told us that our insurance (Mutual of Omaha) just > recently changed their policy and will not longer pay for helmeting > because they consider it a cosmetic issue. I found this site (which > is WONDERFUL) and have been encouraged by all the appeals and wins > against the insurance company so we are planning to fight!!! My > question is do we need to wait until we get a decline letter before > getting his helmet? I think I read an earlier e-mail that if we > don't wait then the insurance company can come back on us and say we > started treatment without authorization. Do we have to wait until > they decline us and we win an appeal before we can start? I really > don't want to put off getting his helmet...from everything I read the > sooner you start the better! I don't know how good of a chance we > have either because the doctor told us if we decided not to helmet > they would support that decision as well. The said it basically is a > cosmetic issue because his brain growth will still be the same. Can > you win without doctor support saying it is a medical necessity? > > Amy (mom of ) > Nebraska Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 6, 2002 Report Share Posted May 6, 2002 Amy: I want to wish you & good luck for Thursday's helmet casting. Will just be getting casted or has that already been done & he'll now be receiving the helmet? As for the insurance, I really don't know about your appeal process, I luckily never went thru any of that. But I do want to suggest that you check out our " bookmarks " section and www.plagiocephaly.org/support for many useful tips that might help. I am glad you have plans to fight fight fight! Please let us know how Thursday goes. Good luck. Debbie Abby's mom DOCgrad MI > My son (5 months tommorow) will be casted and fitted for a > locally made helmet this coming Thursday. The insurance people at > the hospital told us that our insurance (Mutual of Omaha) just > recently changed their policy and will not longer pay for helmeting > because they consider it a cosmetic issue. I found this site (which > is WONDERFUL) and have been encouraged by all the appeals and wins > against the insurance company so we are planning to fight!!! My > question is do we need to wait until we get a decline letter before > getting his helmet? I think I read an earlier e-mail that if we > don't wait then the insurance company can come back on us and say we > started treatment without authorization. Do we have to wait until > they decline us and we win an appeal before we can start? I really > don't want to put off getting his helmet...from everything I read the > sooner you start the better! I don't know how good of a chance we > have either because the doctor told us if we decided not to helmet > they would support that decision as well. The said it basically is a > cosmetic issue because his brain growth will still be the same. Can > you win without doctor support saying it is a medical necessity? > > Amy (mom of ) > Nebraska Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 6, 2002 Report Share Posted May 6, 2002 Hi Amy and welcome! I think it is great that you are planning on fighting your insurance company! You do need to wait for the denial letter before starting treatment, however, you don't have to wait for the appeals to get started. Once you have the denial letter you should ahead and get started because just as you said it is not something you want to put off!! The younger the better for good correction. It is unfortunate your doctor won't give you a letter of medical necessity because that would certainly make an appeal much easier. However, you can also print off tons of information from this page and also try www.cranialtech.com for some good information to print. (even though you are not using a DOCband they are still an excellent resource!) You can still make a case for your baby that the helmet is medically necessary. Good luck and keep us posted! Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 6, 2002 Report Share Posted May 6, 2002 Amy, Good luck at the casting this Thursday- try to have an extra person to help you if possible. It is the worst part of the entire process, but it is literally over in 10 min. and so worth it!! Good luck and keep us posted! ' Mom Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2002 Report Share Posted June 19, 2002 Leana: Sorry to hear you are having such a hard time with all of this. Have you heard back from CT yet? I really don't have much good advice to give you as I never had any insurance issues. But I can't imagine CT sending the information in to your ins. w/o some sort of medical " code " or description stating what Katya is & what they are requesting payment for. It's probably another excuse from your ins. company to drag paying out even longer. From the sounds of it, you've done everything right. What insurance do you have? How is Katya doing in her band? Debbie Abby's mom DOCgrad MI > Hi everybody, > > I was wondering if anybody had the same porblem as I am having right > now with the Insurance. First of all, it took us very long just to > submit the claim. Katya was in the band for more than 2 months, when > the neurosurgeon finally gave us a letter of medical nessecaty (it > was very brief too. Who knows why it took him so long!)Than the claim > was submitted twice by Cranial Technologies and rejected twice. Both > times the reason was: There is no description of the service. The > Insurance Company representative told me that all the info they > received from CT was that some medical equipment was used. no > description, nothing. I left a message for CT yesterday. Now I am > waiting for response and wondering may I should have done something > here differently. May be I need to ask CT to give me copies of all > the papers they send to the Insurance company? Or may be I need to > send to the Insurance company some articles on bands, but than isn't > CT suppose to do it for me? I have no idea what to do now. Katya is > going to be out of her band by the end of July, and we still didn't > get too far with the insurance. > > I will appreciate any advice, > > Leana, Katya's mom (17 months old) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2002 Report Share Posted June 20, 2002 Hi Debbie, Thank you very much for responding. from CT called me and left me a message saying that someone from North Carolina office didn't send what he or she was suppose to send to the ins. co, and today faxed everything over and now we should wait for another 30 days. I will be calling the ins. co. just to make sure they got the info they needed. Of course, all of this makes me upset, but I will go through it because I want my $3,000. It is worth making all additional phone calls. Katya is doing good. Last time we were at CT I asked the specialist who does the adjustements (Charlotte) how bad Katya's plagio was at the beginning of the treatment (because nobody actually ever told me. I always thought it was severe). She said it was moderate, and now it is mild. And she said that Katya will not need a second band. I was not sure how to react. Of course, I was thrilled that Katya will be out of the band so soon and her plagio is mild now. But when I look at Katya's crooked head (on those rare moments when she is out of the band), I start to doubt Charlotte's words. It is still very noticable. To me plagio is " mild " when you can notice it only with the hair being wet. I can see Katya's plagio even through her thick curly hair. When her hair is wet, it is very obvious and it breaks my heart. I am asking myself: is it really mild? There is no doubt that Katya's head improved, but how much??? I guess I will find that out only after the graduation and final casting. Debbie, I saw your daughter's head's pictures on the web-site and it looked great. How is she doing? Give her hugs and kisses from Katya, Leana, Katya's mom. > > Hi everybody, > > > > I was wondering if anybody had the same porblem as I am having > right > > now with the Insurance. First of all, it took us very long just to > > submit the claim. Katya was in the band for more than 2 months, > when > > the neurosurgeon finally gave us a letter of medical nessecaty (it > > was very brief too. Who knows why it took him so long!)Than the > claim > > was submitted twice by Cranial Technologies and rejected twice. > Both > > times the reason was: There is no description of the service. The > > Insurance Company representative told me that all the info they > > received from CT was that some medical equipment was used. no > > description, nothing. I left a message for CT yesterday. Now I am > > waiting for response and wondering may I should have done something > > here differently. May be I need to ask CT to give me copies of all > > the papers they send to the Insurance company? Or may be I need to > > send to the Insurance company some articles on bands, but than > isn't > > CT suppose to do it for me? I have no idea what to do now. Katya is > > going to be out of her band by the end of July, and we still didn't > > get too far with the insurance. > > > > I will appreciate any advice, > > > > Leana, Katya's mom (17 months old) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2002 Report Share Posted June 20, 2002 Leana: Thanks so much for your nice words about my Abby's head! Abby's head is still far from perfect, but after all we went thru with it, I am really VERY happy with our results. She graduated almost a year ago already (6/22/01)...I still cannot believe it! I pulled her band out of the closet last week & couldn't beleive how little her head was compared to now! They grow so fast Now to Katya....if you still feel she needs addt'l correction, then go for a 2nd band. That decision is entirely up to you & your family. Of course with her being 17 mos old, correction would be slow, but she could still hopefully benefit from a 2nd band. It does sound like she's rec'd very good correction so far though! That's terrific . I am also sure that any remaining plagio she may have, will probably only be noticeable to you & others who know about it. I am glad CT got back with you and are taking care of the necessary paperwork. I really thought your ins. was just giving you another line of bull for not paying hehe. Good luck with it all! > > > Hi everybody, > > > > > > I was wondering if anybody had the same porblem as I am having > > right > > > now with the Insurance. First of all, it took us very long just > to > > > submit the claim. Katya was in the band for more than 2 months, > > when > > > the neurosurgeon finally gave us a letter of medical nessecaty > (it > > > was very brief too. Who knows why it took him so long!)Than the > > claim > > > was submitted twice by Cranial Technologies and rejected twice. > > Both > > > times the reason was: There is no description of the service. The > > > Insurance Company representative told me that all the info they > > > received from CT was that some medical equipment was used. no > > > description, nothing. I left a message for CT yesterday. Now I am > > > waiting for response and wondering may I should have done > something > > > here differently. May be I need to ask CT to give me copies of > all > > > the papers they send to the Insurance company? Or may be I need > to > > > send to the Insurance company some articles on bands, but than > > isn't > > > CT suppose to do it for me? I have no idea what to do now. Katya > is > > > going to be out of her band by the end of July, and we still > didn't > > > get too far with the insurance. > > > > > > I will appreciate any advice, > > > > > > Leana, Katya's mom (17 months old) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2002 Report Share Posted June 20, 2002 Leana, Unfortunately it is all too common to see insurance companies stall to avoid payment. Many companies will find any excuse to NOT pay. You may need to get more involved with the process. See if you can find out exactly what it is they need to have included with the claim. CT should be able to handle this, but if there is trouble getting it submitted properly then you may need to get involved. Are you close by the clinic? Maybe you could go down there and meet with the insurance person at the CT clinic. Good luck and hang in there. Keep pushing on it!! Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 20, 2002 Report Share Posted June 20, 2002 Leana, I'm guessing that if you still have some very strong concerns about Katya's head shape when she outgrows her first band that CT will work with you on deciding about a second band. Still, you have some time - maybe she will have a good growth spurt soon and more improvement will occur before graduation. Hang in there! Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 2, 2002 Report Share Posted December 2, 2002 My daughter's claim is under review with United. I'll keep you posted on how it turns out. I've heard they are notorious for denying claims for bands, so be prepared. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 10, 2003 Report Share Posted January 10, 2003 : That is odd! So you haven't rec'd an approval or denial from your insurance company, but yet haven't rec'd a bill from your orthotist office! Hmmmm! Our insurance approved Abby's band coverage of 50% - we rec'd her band in Nov 00, and rec'd our bill the 1st part of Jan 01, so just 2 mos into her band, our ins. paid their portion & we were billed for ours. I suppose no news is good news at this point! Debbie Abby's mom DOCGrad MI > What is the usual amount of time before insurance comes up with an > answer of approval/non approval. was casted almost 5 months > ago and has graduated from her band 2.5 months ago and I've yet to > get billed from the orthotist's office. I received and EOB from the > insurance company about 2 months ago that didn't deny us but said > they needed more information to process the claim. The orthotist > office had called to confirm that our nuerologist has completed all > of the medical necessity paperwork. Is this the usual procedure for > both the insurance company and the orthotist office? As far as I > know the last activity regarding 's band was that the orthotist > office has forwarded the paperwork of med necessity to the insurance > company. AND to make matters even MORE confusing, DH's company has > changed insurance effective Jan 1, 2003, so they will probably wonder > why the heck we had a follow up visit with the nuerologist. I'm > getting a headache just writing this post. Any info would be great!! > Thanks in advance for all your help > > & (9.5 months, STARband Grad) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 17, 2003 Report Share Posted February 17, 2003 Hi Dawn, I don't know if this will help you or not, but hopefully so! It is an appeal letter that someone else used. They were denied on the same grounds. Good luck and please keep us posted. August 31, 2001 Appeals Coordinator United Healthcare P.O. Box 740800 Atlanta, GA 30374-0800 RE: Patient: Employee: ID#: Group#: Group: To Whom It May Concern: We received your denial of coverage from XXXXX via telephone on July 13, 2001. Additionally, we are in receipt of your form letter of July 20, 2001 denying coverage for our son's thermoplastic molding helmet intended to treat his skull deformation. This letter states that this helmet is considered cosmetic treatment and that our son has no functional impairment that would be improved by the thermoplastic molding helmet.1 We are at a loss to understand this decision and we are confident that once you review the specifics of XXXX's case, you will correct this error and do the right thing by paying for his helmet. Our appeal is based on the following considerations: 1. On July 5, 2001, XXXX's physician, Arno Fried, M.D., F.A.C.S., Director of Pediatric Neurosurgery at Hackensack University Medical Center, prescribed the helmet for XXXX and ordered X-rays and a CT scan to rule out craniosynostotis. Dr. Fried's letter of medical necessity explains that the helmet is necessary to correct XXXX's bilateral occipital plagiocephaly and that XXXX has torticollis, gross and fine motor delays and sensory processing issues. This is Dr. Fried's second letter to you after you requested more information. Dr. Fried also writes that XXXX needs to get " this helmet soon to ensure the best possible outcome. " 2 Copies of the reports from XXXX's CT scan and X-rays are attached.3 At the time of the studies, the entire back of XXXX's head was flat, with the shape being like a trapezoid when viewed from above. There was significant bossing of his forehead with some facial asymmetry. This is typical in brachycephaly. 2. We pursued a consultation with Dr. Fried after having XXXX examined on June 20, 2001 by Dr. Bello, a developmental specialist affiliated with Albany Children's 2 Medical Center in Albany, NY and a noted expert on sensory processing deficits in children. XXXX was 38 weeks old at the time of the examination. Dr. Bello reports that " XXXX has hypotonia associated with a gross and fine motor delay, at about 26 to 28 weeks. " Further, he refers to XXXX's " significantly flat occiput " and recommends that we get " a second opinion from a pediatric orofacial surgeon, regarding the flattening of his occiput and the need for any intervention at this time. " 4 3. XXXXXXX, a registered physical therapist (NYS State License #XXXXX) has been treating XXXX for his torticollis and subsequent motor delays since March 2001. Additionally, she has provided us with instructions and guidance on stretching XXXX and repositioning him in an effort to help the torticollis and reduce the pressure on his occiput. We have been extremely diligent in pursuing Ms. XXXX's stretching and repositioning exercises. However, since XXXX has a significant delay in his motor skills, he is not able to reposition himself and his sensory issues made him very resistant to our efforts to reposition him. Attached is a letter from Ms. XXXX detailing our son's history and course of treatment. She states that XXXX's " occiput has become severely flattened in the rear " .5 Ms. XXXX has told us during the course of XXXX's treatment, that XXXX has the flattest head she has ever seen in her professional career of over 15 years. 4. According to the American Medical Association's Resolution 119 on Coverage of Children's Deformation, Disfigurement and Congenital Defects, the AMA is aware of insurance companies and HMO's denying benefits for treatments of craniofacial deformities, disfigurements and congenital defects because the companies CLAIM these problems are non-functional and thus considered " cosmetic " in nature and therefore are a non-covered disorder. This resolution plainly states that " CHILDREN WHO DO NOT HAVE BIRTH DEFECTS AND FACIAL ANOMALIES REPAIRED FACE LONG TERM PHYSICAL AND PHYCHOLOGICAL INJURIES… " AMA policy goes on to state " COSMETIC surgery (therapy) is performed to reshape NORMAL structures of the body in order to improve the patient's appearance and self-esteem. RECONSTRUCTIVE surgeries (therapies) are performed on ABNORMAL structures of the body, caused by congenital defects, developmental deformities…are performed to IMPROVE FUNCTION. " 6 The thermoplastic molding helmet prescribed by Dr. Fried is an FDA approved device. The FDA has also said that this condition is a functional and not cosmetic problem. We assume that the physician reviewing this appeal for United Healthcare is a member of the AMA and would not recommend action contrary to AMA standards. 5. There is ample evidence to support long-term physical effects due to untreated deformational plagiocephaly. At the 38 th annual AOA conference, B.F. Degenhardt, D.O., et al. presented findings regarding the relationship of head shape to otitis media. They observed that " those children who had plagiocephaly…had an increased risk of middle ear infections. " 7 Additionally, non-treated positional plagiocephaly has been linked to migraine headaches, difficulty chewing, TMJ and respiratory and vision problems. R.I. and S.K. Clarren, in a paper published in the journal 3 Pediatrics, examined links between developmental delay and deformational plagiocephaly and concluded that " infants with deformational plagiocephaly comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. " 8 Persing, M.D., chief of Plastic Surgery at Yale University medical Center, says that a flat head can " single out a child for unwanted problems later on that could be due to physical distortions in the face as well as the skull. That's because when you have a flattening in the back of the skull, it often has facial effects not only in the cheekbones but in the jaw. If there's enough of a distortion, kids can pick up on that and, particularly around 5 or 6 years of age, it can be a real problem for children in terms of being accepted within their intended peer group, in how they socialize and even how they do in school. " 9 As parents, we are unwilling to allow such physical, developmental and psychological problems to arise when a non-invasive treatment is available to help prevent and correct them. 6. There are numerous correlating factors shown to influence the development of plagiocephaly. We have found repeated mention of the following precipitating factors (to only name a few)10 : · Restrictive intrauterine environment · Poor muscle tone (hypotonia) · Torticollis · Cervical-vertebral abnormalities · Sleeping position As noted earlier, XXXX has a developmental delay, hypotonia and torticollis. Additionally, due to XXXX's delay and sensory issues, he slept on his back well beyond the time when other infants are able to reposition themselves. 7. United Healthcare PPO plan has paid for thermoplastic molding helmets for patients with diagnoses identical to my son. In a recent case, IPRO, the agency that handles external appeals for the NYS Insurance Commissioner, reversed United Healthcare's decision to deny coverage for an FDA approved helmet as treatment for positional plagiocephaly. In this case, the infant had plagiocephaly and torticollis, as does XXXX. UHC turned down the treatment for the same reasons that you gave us: " no functional deficit…and the band would just be to improve appearance. " As we plan to appeal an unfavorable decision externally, the insurance commissioner's finding is important. Referring to the helmet, the reviewer writes: " This device is not used for COSMETIC purposes, but rather for RECONSTRUCTION. Cosmetic surgery is defined as surgery used to reshape normal structures of the body…to improve a patient's appearance. This patient had a deformity of the skull caused by head position. If left untreated, the ears 4 can also move into abnormal positions. This baby's head was not normal. This is clearly not cosmetic treatment and should be considered a covered benefit. Please see Neurosurgery Focus 9 (3), May 2000. This device is the preferred method of treating positional plagiocephaly after repositioning and physical therapy have failed. THIS IS THE STANDARD OF CARE FOR THIS DISORDER. Therefore, the decision of UHC to deny coverage for a dynamic orthotic cranioplasty band should be reversed. " 11 Because our doctor recommended this treatment (and emphasized that we should begin quickly in order to preserve the chance for the best outcome) and despite United Healthcare's initial refusal to cover the cost of XXXX's thermoplastic molding helmet, we have proceeded with the prescribed treatment at significant financial hardship to ourselves. Our options, as we saw them, were as follows: a. No treatment. Given the fact that XXXX already has an uphill struggle ahead of him due to his torticollis, gross and fine motor delays and sensory processing issues, we thought it would be entirely foolish and unacceptable to further complicate his life by exposing him to well-documented psychological, physical and developmental problems due to his plagiocephaly. No one can be certain that some of XXXX's current delays are not due at least in part to his severely flattened head. Further, as XXXX was almost 11 months old, we did not have the luxury of waiting to see if his condition would worsen to the point where UHC would deem the helmet medically necessary or to postpone treatment while your decision was on appeal, as the optimal time to begin helmet therapy is before one year of age. b. Surgical Intervention. While surgery was not immediately deemed necessary, had XXXX's condition continued to worsen, it may well have been required. The cost of surgery could easily exceed twenty times the cost of the Hanger helmet. This helmet is a functional orthotic. Almost all carriers have underwriting for a functional orthotic because the replacement treatment is usually as effective at a fraction of the cost. Risks due to surgery are obvious and we had no desire to put our son through a great deal of pain and suffering when a less expensive, equally effective, non-invasive option existed. c. FDA approved Thermoplastic Molding Helmet from JE Hanger, 317 E. 34 th St, NYC. This non-invasive, relatively inexpensive, pain free procedure was by far the best option. This helmet is identical to the STARband by Orthomerica. At a price of $1450.00, it costs less than half of another FDA approved device, the Dynamic Orthotic Cranioplasty Band by Cranial Technologies and works just as well. Given that we diligently performed physical therapy and repositioning without correction for over 5 months, the helmet was the next logical step. Thank you for your time regarding this matter. 5 Sincerely, XXXXXXXX XXXXXXXXX Enclosures Cc: Arno Fried, M.D., Hackensack University Medical Center Brown, JE Hanger, Manhattan Commissioner of Insurance, State of New York 1 HARRINGTON, BARBARA,RN, LETTER: PREDETERMINATION, UNITED HEALTHCARE,JULY 20, 2001. 2 FRIED, ARNO,MD, 2 ND LETTER OF MEDICAL NECESSITY, JULY 27,2001. 3 CT SCAN AND X-RAY REPORTS, HACKENSACK UNIVERSITY MEDICAL CENTER, JULY 12, 2001. 4 BELLO,SCOTT,MD, REPORT ON RESULTS OF XXXXX'S DEVELOPMENTAL EVALUATION, JULY 20, 2001. 5 PHYSICAL THERAPIST., LETTER DETAILING XXXX'S DELAYS, COURSE OF TREATMENT AND HEAD DESCRIPTION, JULY 28, 2001. 6 AMA HOUSE OF DELEGATES, RESOLUTION 119 (I-97), SUBJECT, COVERAGE OF CHILDREN'S DEFORMITIES,DISFIGUREMENT AND CONGENITAL DEFECTS, INTRODUCED BY: AMERICAN SOCIETY OF PLASTIC AND RECONSTRUCTIVE SURGEONS AMERICAN SOCIETY OF MAXILLOFACIAL SURGEONS AMERICAN ASSOCIATION OF PLASTIC SURGEONS AMERICAN ACADEMY OF CHILD AND ADOLESCENT PHYCHIATRY AMERICAN COLLEGE OF SURGEONS AMERICAN PEDIATRIC SURGICAL ASSOCIATION AMERICAN SOCIETY FOR SURGERY OF THE HAND 7 DEGENHARDT,B.F.,M.D., " CRANIAL DYSFUNCTION IN OTITIS MEDIA " , 38 TH ANNUAL CONFERENCE ABSTRACTS, 1994. 8 MILLER,R.I.,M.D., AND CLARREN,S.K.,M.D., LONG-TERM DEVELOPMENTAL OUTCOMES IN PATIENTS WITH DEFORMATIONAL PLAGIOCEPHALY,PEDIATRICS, Vol. 105, No.2, 2/00, p.26. http://www.pediatrics.org/cgi/content/full/105/2/e26 9 MELVILLE,NANCY,BABY MOLDS:SHAPE OF THEIR FUTURE STARTS WITH THEIR HEADS, Health Scout News, August 19, 2001. HTTP://WWW.SAFETYALERTS.COM/T/HS/MOLDS.HTM 10 GRAHAM,J,CSMC PEDIATRICS/MEDICAL GENETICS:MANAGEMENT OF PLAGIOCEPHALY AND TORTICOLLIS, AHMANSAN PEDIATRIC CENTER/CEDARS SINAI MEDICAL CENTER. http://www.csmc.edu/PEDIATRICS/REFGUIDE/HELMET/HELMET.HTML 11 IAQUINTA, FRANK, M.D., IPRO FOR NEW YORK STATE INSURANCE DEPARTMENT, LETTER TO ANG DONG, 6/26/01. > Hi ! > > I just received the denial for our first appeal with BlueCross > BlueShield of NC for teh DOC band. Does anyone have any good advice, > articles, etc. to use when fighting a " cosmetic purposes " appeal. It > appears as if the reviewers didn't read ANY of the appeal information > which included an article (that I found in the files section) that > talked about long-term developmental issues. We will be filing the > second appeal shortly but wanted some new amunition. Also, does > anyone know or have the e-mail address of ? She > listed in the database that BCBS of NC had paid her claim. Thanks in > advance. > > - Dawn Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 18, 2003 Report Share Posted February 18, 2003 Dawn I to am writing blue cross for the denial for cosmetic reasons so if I find anything wonderful I will let you know. I just started doing the search and have really only pulled up the obviose stuff in the files but I will def. let you know what I come up with. Debbie belle's-mom > Hi ! > > I just received the denial for our first appeal with BlueCross > BlueShield of NC for teh DOC band. Does anyone have any good advice, > articles, etc. to use when fighting a " cosmetic purposes " appeal. It > appears as if the reviewers didn't read ANY of the appeal information > which included an article (that I found in the files section) that > talked about long-term developmental issues. We will be filing the > second appeal shortly but wanted some new amunition. Also, does > anyone know or have the e-mail address of ? She > listed in the database that BCBS of NC had paid her claim. Thanks in > advance. > > - Dawn Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 8, 2008 Report Share Posted September 8, 2008 We are filling out an application for a new group insurance policy and there is a question on there called " Behavioral Health " . It asks if you or a family member has any of the conditions and autism is one of them. My 10 y.o. son has a diagnosis of Autism Spectrum Disorder, but I am afraid to check this box---what should I do? Thanks. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 10, 2008 Report Share Posted September 10, 2008 Thank you Sandee, that helps me tremendously!! From: Sandee <jswinky@...>Subject: Re: [ ] Insurance Question Date: Tuesday, September 9, 2008, 10:27 AM From what other parents have shared with me and my own research as a parent regarding the very same it appears that most children on the spectrum are not diagnosed with behavioral health issues. Most behaviors for children and adults on the spectrum are a means of communication and or reaction to their environment due to sensory issues. Unless your child has a a specific mental health diagnosis you should be able to leave the box blank since autism is recognized as a neurological disability.Hope this helpsSandee WinkelmanParent Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 28, 2010 Report Share Posted June 28, 2010 Hey , You can contact me off-list and I can help you go thru the process. I work in insurance billing for speech and OT. I need more info on your policy guidelines (benefits) to give you any info. TTYL, ________________________________ From: <rogerbruneau@...> " " < > Sent: Wed, June 23, 2010 11:48:48 AM Subject: Insurance Question  Does anyone use AETNA as an insurer? If so any luck getting them to cover OT and speech therapy? I am starting an appeal process and would appreciate any hints. Thanks, Bruneau Sent from my iPhone Quote Link to comment Share on other sites More sharing options...
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