Guest guest Posted February 4, 2002 Report Share Posted February 4, 2002 DENIED first off let me say..sorry so long!!! k, here is where we stand. they denied us, i appealed, and now we got the denial letter..here is some good reading for you all..it says:"the use of dynamic orthotic cranioplasty to treat patients with nonsynostotic occipital plagiocephaly has been deemed investigational. current available scientific evidence does not support conclusions concerning the effectiveness nor medical necessity of the treatment of the condition referred to as positional plagiocephaly. our denial was based on the treatment as being not medically necessary as there is no functional impairment. under the limitations and exclusions section fo the plan, there are no benefits for treatment of a congenital disease or anamaly except to correct a funtion (underlined) defect...the plan does not provide benefits for services not medically necessary for diagnosis and tretment of an injury or sickness. medically necessary is defined in the plan as "the extent of services required to diagnose or treat an injury or sickness which is known to be safe, effective and approriate by most qualified practitioners who are licensed to treat that injury or sickness. such services must be performed in the least costly setting required by the patients condition and must not be proviede primarily for the convenience of the patient, the patient's family or the qualified practitioner" it is well known that positional plagiocephaly due to torticollis can be successfully treated by positional rotation combined with activae and passive stretching excercises. in addition, positional plagiocephaly is not associated with funcional impairment. also, because the use of doc headband is still investigational, under the limitations and exclusions section of the plan, the plan does not provide benefits for any medical or surgical procedure, which is considered experimental or investigational....based on the limitations and exclusions of the plan, the doc headband was denied because this treatment is considered not medically necessary, investigational and because there is no documented funtional impairment..if you have further questions or would like to appeal or decision, please feel free to write your local american arbitration association..so that is the letter...long huh..and i even cut some stuff out!!HELP..what do i do..p.s..i hope they werent refering to my son when they said torticollis because he don't have it..at least i was never told he did..so..what do you all think...maybe the doc clinic people can help!!For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2002 Report Share Posted February 4, 2002 i have alliance/midwest securtity out of wisconsin..sorry about your denial..you are on your second...man..what do you think i should do..sorry to hear about your problems..hopefully someone can help us both!! > > DENIED > > > first off let me say..sorry so long!!! k, here is where we stand. > they denied us, i appealed, and now we got the denial letter..here is > some good reading for you all..it says: > " the use of dynamic orthotic cranioplasty to treat patients with > nonsynostotic occipital plagiocephaly has been deemed > investigational. current available scientific evidence does not > support conclusions concerning the effectiveness nor medical > necessity of the treatment of the condition referred to as positional > plagiocephaly. our denial was based on the treatment as being not > medically necessary as there is no functional impairment. under the > limitations and exclusions section fo the plan, there are no benefits > for treatment of a congenital disease or anamaly except to correct a > funtion (underlined) defect...the plan does not provide benefits for > services not medically necessary for diagnosis and tretment of an > injury or sickness. medically necessary is defined in the plan > as " the extent of services required to diagnose or treat an injury or > sickness which is known to be safe, effective and approriate by most > qualified practitioners who are licensed to treat that injury or > sickness. such services must be performed in the least costly setting > required by the patients condition and must not be proviede primarily > for the convenience of the patient, the patient's family or the > qualified practitioner " it is well known that positional > plagiocephaly due to torticollis can be successfully treated by > positional rotation combined with activae and passive stretching > excercises. in addition, positional plagiocephaly is not associated > with funcional impairment. also, because the use of doc headband is > still investigational, under the limitations and exclusions section > of the plan, the plan does not provide benefits for any medical or > surgical procedure, which is considered experimental or > investigational....based on the limitations and exclusions of the > plan, the doc headband was denied because this treatment is > considered not medically necessary, investigational and because there > is no documented funtional impairment..if you have further questions > or would like to appeal or decision, please feel free to write your > local american arbitration association.. > > so that is the letter...long huh..and i even cut some stuff out!! > HELP..what do i do..p.s..i hope they werent refering to my son when > they said torticollis because he don't have it..at least i was never > told he did.. > > so..what do you all think...maybe the doc clinic people can help!! > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 4, 2002 Report Share Posted February 4, 2002 Well, it looks like they have thrown everything in the book at you. Please check out our files section under insurance help. There is some very helpful information located there that might help you to figure out where to start. You can and should appeal. As far as the investigational part - the DOC clinic can certainly help with that. The DOCband is FDA approved and not considered investigational. Do you have a letter of medical necessity from your specialist or ped? If not you need to get one as soon as possible. Some drs will write them quickly for you, others will need a lot of reminding and some won't do it at all. A letter of medical necessity will help significantly. In the insurance help section you will find some successful letters of appeal. That is where I started when writing my appeal. Make sure you document like CRAZY. Keep a detailed phone log of everyone you talk to and keep copies of absolutely everything whether or not you think you will need it. You definitely have a chance to fight this. Try to break it down into parts and address each of the reasons for denial separately within the same letter. You can do it - it seems overwhelming now, but you can do it! Good luck and let me know if I can be of further assistance. Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2002 Report Share Posted February 7, 2002 , Does your policy cover durable medical equipment (DME)? Sorry to hear about the denial. These insurance companies can be so very aggravating. I know that United Healthcare does sometimes cover orthotics because we have people in this group who have had the DOCband covered by UHC. Is it just that your specific policy type doesn't cover orthotics? I think it is very, very wrong of your insurance company to tell you that you have that type of coverage on the phone and then tell you in writing that you don't. Have you considered filing a Department of Insurance complaint against your company? Just a thought - it wouldn't hurt. Also, if you have the insurance through work can your Human Resources department maybe lend you a hand? So sorry about all the trouble - insurance is truly one of those things that you " can't live with and you can't live without " . Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
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