Insurance help!!

[Guest guest]

My daughter got her helmet last Friday, ten days after she was

casted. At the time of casting she was seeing a physical therapist

for her tort. She got one referral for an intial consultation and

then she received another referral for (4) more visits with the

physical therapist. The therapist recommended a helmet for her at

the second visit and told me she would be writing up a report to give

to my primary care physican for this purpose. Two weeks later the

orthodist was at her physical therapy appt. ready to cast. I asked

him if he had verification from my insurance for the helmet. He told

me not yet, but he was sure that they would accept it. He also told

me if for some strange reason (which does not seem so strange now)

they denied it, we would not be charged a fee for the casting. He

also said that they would not go ahead with the making of the helmet

unless they had verification. When we went to pick up the helmet I

never even asked about the insurance, I just figured they had

approved it. Well, four days later we received a letter from our

insurance (M-CARE) denying to pay for the helmet. They said it was

considered a " protective helmet " .

The company that made the helmet told me that they got a

authorization number sent to them on March 25th. The denial letter I

received was dated March 22. I called the insurance company and they

basically said that it was sent in twice and denied both times.

Anybody else out there have problems of this sort? M-CARE is a

University of Michigan insurance company. Anybody have any

experience with this company?

I am so frustrated because my daughter is already in her helmet and

tolerating well. We will continue with her helmet even if the

insurance company decides not to pay for it. But, I am determined to

fight this for how ever long it takes.

Thanks for any help,

Helen and

[Guest guest]

Helen,

I don't have any experience with your specific insurance company, but I would

very much encourage you to fight it since the helmet is most decidedly NOT

for protection - what a bunch of crap! You should be able to appeal that

reason pretty darn easily. See if you can get a letter of medical necessity

from your dr, that will help with your appeal. You could also file a

complaint with your state's department of insurance. See if you can get a

copy of whatever authorization number your ortho's office got - that should

come in handy with your appeal. Give your insurance company a call and ask

for a copy of their appeals guidelines so you can be sure you file it in the

correct manner. Keep copies of absolutely everything and keep a really

detailed phone log of time, date, name and subject matter of all calls made

in regards to the helmet.

Good luck with this and hopefully the insurance co will come to their senses

and pay for it.

Marci (Mom to )

Oklahoma