Insurance Denial- AGAIN!!!??

[Guest guest]

Well, they've done it again. Remember how I had to call the insurance

company and ask about the denial based on an out of network provider?

Well, now they are denying it saying that it is " considered an

exclusion under the member's plan. " Huh??

I still have the letter " authorizing custom 'Starband' cranial

helmet " dated Nov 5th.

I looked up the exclusions in my certificate of coverage (I have

HealthNet HMO, now Mid-America Health HMO) and under Durable Medical

Equipment I can find two reasons they may have denied it- Items deemed by

HealthNet to be experimental or research equipment AND Durable Medical

Equipment that is not medically necessary.

On Monday I'll have to find out which one they are using and work on an

appeal letter. I feel like I shouldn't have to because we got what I

thought was prior authorization. We waited until after we got the letter

to get him casted and seriously considered not treating him if we the

insurance wouldn't cover it. Now it's too late to give it back...

Debi and (STARBand 11/29/01)

near Kansas City

[Guest guest]

Debi,

ARGH!!! I feel your pain! Insurance denials are no fun at all...we

went through 3 with our provider. The bad news is we had to go

through 3 denials and fight tooth and nail to get Leigha's DOC band

approved...the good news is we finally won on a third level appeal.

Its a trying and stressful process to go through and I think there

are a lot of people here who would like to blow up HMO's(I know what

Rehab designs and Dr. Bob think of the moron who fought us for

covering the DOC band.*wink*) Keep fighting...it might be a long

process but it will definatly be worth it when you win - just

remember its nothing personal on you...just the HMO trying to keep

their money...the worst thing in our case was that our insurance

didn't have to even pay full price on the band..they only were

required to cover 45% of the band but they still had to be stupid

about it.

Good luck and hang in there!

- Kansas City, MO

Proud mommy of Austen 12/21/96 and *Leigha 7/22/00

* bicoronal cranisynostosis dx 2/14/01

craniovault reconstruction with front orbit advance 5/01/01

DOC band 5/25/01 - 9/26/01

PS where near Kansas city are you?

>

[Guest guest]

Debi:

What a bummer. Follow Mel's advice & fight til the end! I would be

so frustrated too, esp. with your Preapproval letter saying they

would cover it. I would have flipped out if that happened to me!

If they do say their reason for denial is becuz it's " experimental " ,

you can fight that one to the end. The STARband is not

experimental. It is FDA approved, it is a proven product. Many

insurance companies do try to use the experimental excuse to not

cover the bands. Fight, fight fight!

Keep appealing. It's worth a fight.

Debbie Abby's mom DOCgrad

MI

>