Guest guest Posted January 9, 2002 Report Share Posted January 9, 2002 In a message dated 1/9/02 4:08:16 AM Pacific Standard Time, jlkittredge@... writes: We have had to switch insurances since the first band was approved and have been promptly DENIED any benefits for Will's 2nd band for the following stated reason "The use of a cranial orthosis or remodeling band or helmet for the diagnosis of positional plagiocephaly is not considered to be medically necessary as it does not correct or improve a bodily function. We are unable to authorize any benefits for this item." Does anyone have any words of advice on how I could fight this? If so, I would greatly appreciate it. Oh I feel your pain. Are you familiar with the files section of this group and other plagio groups? There are lots of good documents in the files section that I recommend you print off and read for starters. It will help you get ready to write your appeal letter. There are many good successful appeal letters in there too. I am currently working on our 2nd appeal letter. My daughter only had one band and the insurance company is refusing to pay for it so your case is a bit different and I think it is great that your first insurance company paid some and you should use that fact in your letter (I think) Check out the files section by going to the plagio group main page and click on files then click on the various documents and print them out and read them all and they will get ya started. (mommy to 22 mos and just mommy to an unknown little one....just had a postive pregnancy test this a.m.) Yeah!) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 9, 2002 Report Share Posted January 9, 2002 Hello Plagio Parents, My son at 6 mo. was labeled with a " severe case " of positional plagio. Our first insurance covered 50% of his current DOCband, which was great. The time has come for my son to enter his second band, which in the beginning we were told he was probably going to need. We have had to switch insurances since the first band was approved and have been promptly DENIED any benefits for Will's 2nd band for the following stated reason " The use of a cranial orthosis or remodeling band or helmet for the diagnosis of positional plagiocephaly is not considered to be medically necessary as it does not correct or improve a bodily function. We are unable to authorize any benefits for this item. " Does anyone have any words of advice on how I could fight this? If so, I would greatly appreciate it. Thanks! in Michigan Mother to (9 1/2 mo) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 9, 2002 Report Share Posted January 9, 2002 You are probably in for along battle withyour new insurance company-but don't give up!!! Following are some links that will be helpful for you if you have trouble accessing them let me know and I will send them in another form. Good Luck and Keep us posted on your battle. What type of insurance do you have????? Beck : Plagiocephaly Files Insurance Issues and Support Click here: State Insurance Departments Click here: Plagiocephaly Information Center - Cranial Technologies, Inc. Click here: Research Links Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 9, 2002 Report Share Posted January 9, 2002 > Following are some links that will be helpful for you if you have > trouble accessing them let me know and I will send them in another form. Beck: I just wanted to say how helpful all the links are to everyone! Thanks! Debbie Abby's mom MI Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 10, 2002 Report Share Posted January 10, 2002 I don't know if your DR. S could help or not but when I got my letter from the insurance company that they would not pay I was on the phone quick! I told the lady that I did not see how they could tell me that my son did not need a helmet when they had never even seen him. Before i could vent to much she asked me when my letter had been written, and when i told her she said don't worry about it your dr. has already called and taken care of it. and it was covered. sherry Mom to mason Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 6, 2002 Report Share Posted March 6, 2002 Dear Jackie, I have Health Net, and I was turned down for my son's Oral/Verbal Dyspraxia. I went through all the appeals with the insurance co. and I contacted New Jersey State, Dept. of Health and Senior Services. I was told that I could then appeal through the state, it cost $ 25.00 on my end. They have to read over everything you submitt and then decide if you have a case. I submitted a cover letter I wrote, and the Speech/Language Eval. Info. from the Neuro. and a letter of Medical Necess. from his doctor. I won, I was given 30 sessions a year. Not great but it is something. You could also try contacting your local school district to have speech provided through pre-school early ed. I have been doing that as well for the last 6 years, the only problem is that I learned the hard way, you should make sure they have a speech teacher who is trained and famil. with Apraxia. When my son started at the school I had a different diagn. which was just Articulation/Phonological and know since I had him evaluated twice since then he is know correctly been diagn. with Dyspraxia. I also homeschool him because the school district was not going to give him the help he needed. Good luck, Kathy feel free to contact me. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 6, 2002 Report Share Posted March 6, 2002 Hi there, Healthnet has a history of giving their customers a run around like this. I would turn down the level two phone thing and start requesting a hearing before their board that handles customer's appeals for denial of coverage. That way you can have your experts testify on your behalf or submit affidavits in writing about their conclusions and plans for treatment. You also can speak before real people about your child's needs. You do not need a lawyer yet. There are health care professionals usually nurses who have lately started specializing in helping consumers navigate the HMO nightmare maze. Some of these specialize in handling medicare cases, but a few contacts might give you some leads on someone who will help you with this. If all else fails, then by all means consult a lawyer. Just remember, it's a waiting game, the louder you are, the more you bug them the greater chance you have to get your child's therapy covered. They try to hold out as long as possible with all kinds of excuses, but you can be strong for your child and outlast them. Best wishes for your success. We fought for a year and finally our insurance company covered the therapy which was included in our plan in the fine print, they just thought they could deny, deny, deny and we would go away but it didn't happen that way. Stay strong. B. >From: prupru@... >Reply- > >Subject: [ ] Insurance Denial >Date: Mon, 4 Mar 2002 16:42:52 EST > >My insurance Co, Health Net has denied speech therapy for my 4.5 y.o.son >with >verbal apraxia. At first they stated that he would not make any >significant >progress within 2 months (the maximum period of coverage). When I sent >notes >from my SLP to dispute this, they changed to saying that verbal apraxia was >not a congenital disorder. Although, Dr. Agin sent them a letter about >this, >they continue to deny therapy. > >They are now offering me a level 2 appeal which is done by phone. I >requested that a Neurodevelopmental Pediatrician and a SLP with childhood >apraxia experience be included in the evaluation. I was told that they are >not required to do this. > >Any suggestions on how I should proceed? I will file a complaint with the >Insurance Board, but I am not expecting much from that. Should I hire a >lawyer? I know it sounds like alot of effort to get them to pay for a very >limited benefit, but at this point it has become a matter of principle. I >just can't understand how an insurer can flatly refuse coverage for a >service >that meets the benefit criteria. > >Thanks for the help. >Jackie > _________________________________________________________________ Join the world’s largest e-mail service with MSN Hotmail. http://www.hotmail.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 6, 2002 Report Share Posted March 6, 2002 Jackie, I am sorry to hear that your insurance co. wll not cover your needs. I just don't understand why these insurance co. do not think that speech therapy is not a need. What is the insurance for anyways?????? These are medical needs that they should be covering. Nothing makes sense anymore! I had found out through someone I know who put there son in therapy that sometimes the ones who make the diagnoses on your child HAVE to stretch the truth a little bit and make a diagnoses more severe than it really is. My suggestion is that...ask them if they can make it more severe than it really is. That is what my speech therapist did when my son was evaluated. Knowing that most insurances do not cover this type of need...they want there money no matter what so it won't hurt them either way. My sons therapy is covered and I have already recieved what the insurance co sends to let me know what has been billed...so far each therapy session is 194.00 for a half an hour 2x's a week. Seems like alot...just hoping it is well worth it. Good luck to you >My insurance Co, Health Net has denied speech therapy for my 4.5 y.o.son with >verbal apraxia. At first they stated that he would not make any significant >progress within 2 months (the maximum period of coverage). When I sent notes >from my SLP to dispute this, they changed to saying that verbal apraxia was >not a congenital disorder. Although, Dr. Agin sent them a letter about this, >they continue to deny therapy. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 6, 2002 Report Share Posted March 6, 2002 We are going through this also. Do they cover speech therapy for anything? If so, what? My daughter has brain damage, and our insurance does cover speech therapy to " restore " her speech. That's what we now have to prove. Suzi > My insurance Co, Health Net has denied speech therapy for my 4.5 y.o.son with > verbal apraxia. At first they stated that he would not make any significant > progress within 2 months (the maximum period of coverage). When I sent notes > from my SLP to dispute this, they changed to saying that verbal apraxia was > not a congenital disorder. Although, Dr. Agin sent them a letter about this, > they continue to deny therapy. > > They are now offering me a level 2 appeal which is done by phone. I > requested that a Neurodevelopmental Pediatrician and a SLP with childhood > apraxia experience be included in the evaluation. I was told that they are > not required to do this. > > Any suggestions on how I should proceed? I will file a complaint with the > Insurance Board, but I am not expecting much from that. Should I hire a > lawyer? I know it sounds like alot of effort to get them to pay for a very > limited benefit, but at this point it has become a matter of principle. I > just can't understand how an insurer can flatly refuse coverage for a service > that meets the benefit criteria. > > Thanks for the help. > Jackie Quote Link to comment Share on other sites More sharing options...
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