Successful appeals letter

[Guest guest]

This is an email I got from a friend of mine whose twins have plagio. She is not a member of this group, but I thought I'd forward this to you because she managed to get a denial overturned in about 2 days flat. I thought her letter would make a good prototype for those of you out there who are having similar problems with your insurances.

Luck to all,

Jill Ramos, Las Vegas, NV

Appeals letter:

To Whom It May Concern:

I was deeply upset to receive the denial letter from HealthNet regarding the upcoming DOC bands for my children, and . I feel this decision has been made in error and against the specifications and outlines of our coverage with HealthNet. The DOC band treatment is extremely time sensitive, and we simply do not have 30 days to wait on an appeals process--the treatment must proceed NOW or the damage will be permanent to my children.

1. This treatment is not a matter of cosmetics--my children were born with severe plagiocephly and torticollis, due to in-utero positioning. They have been developmentally delayed by their head and neck/jaw problems. We have been aggressive in seeking PT, OT and DOC band treatment, as the time window for treatment is extremely narrow---treatment must be completed by 18m of age, as it is ineffective after that age. The twins turned 12m yesterday, and its recommend they spend at least another 5-6m in the band. As you can see, we have zero time for waiting and appealing -- continued treatment must be immediate.

2. You (PHS/HealthNet) paid for their DOC bands last year, at a rate of 50% under the DME clause of our coverage. We have been undergoing DOC band treatment continually for many months now, and it would be extremely detrimental to change treatment methods at this point. It is unfair to cancel coverage for their treatment mid-treatment! It would harm them to stop treatment at this point, or to change treatment at this point. We knew when we started we would have to commit to the entire treatment--and PHS/HealthNet confirmed to us via telephone that we have 50% DME coverage and it would pay for the DOC bands (as indeed, you did in July and August 2001). We chose our coverage for 2002 solely because we knew we would need continued coverage for these bands in 2002.

3. Their doctor, Dr. Jon Persing of Yale Cranio-Facial, is a world-renowned pediatric specialist (and a participating member of HealthNet). He recommends and prescribes only DOC bands and no other kind of passive or dynamic helmet.

4. Finally, and most importantly: your denial letter states to contact NE Orthotics and Hanger Orthotics for DOC bands. While both make cranial helmets, NEITHER OF THOSE ORTHOTISTS MAKES DOC BANDS AND BOTH HAVE CONFIRMED THIS TO ME IN PHONE CONVERSATIONS. So your statement that we can get this from them is 100% false. DOC bands are available only from Cranial Technologies.

I need this to go to the appeals committee immediately. We are due to be re-cast this week (the week of March 25th) as the children have outgrown their current bands. I am on Social Security disability and we can barely make payments on the 50% that you won't cover. But you must cover the 50% of DME per our contracted coverage.

Please call me Monday, March 25th, to discuss ASAP.

Sincerely,