Time to appeal.....Principal Insurance! All help appreciated! (VERY LONG!!!!)

[Guest guest]

Hi!

I first noticed my son to have plagiocephaly at 2

months. I tried the repositioning techniques for 2

months but the condition actually worsened. At 4

months, my Pediatric PA referred me to a craniofacial

surgeon who recommended a DOC Band as we had already

been doing repositioning. (I am a Physician Assistant

and had some articles on Plagiocephaly already).

He was casted and in a band within 2 weeks. He

remained in the band for around 2 and 1/2 months with

wonderful improvement. We decided not to have another

band put on as we were very happy with the results and

so was the Craniofacial Surgeon.

The

Craniofacial Surgeon wrote a compelling letter of

medical necessity.

Still....despite all of my input as a Medical

Professional, I recieved a denial.

It was very short and basically all it said was that

" 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 ot improve bodily function). As suchm no

benefits are available under this plan.

That was it!

I had already sent documentation.

I was told by Cranial Technologies in Atlanta that

they had never recieved coverage by Principal.

However, when I went for precertification, and I asked

them what chance I had for coverage, they told me a

50-50% chance.

That was in January.

Finally, in April, I recieved our denial letter as

stated above.

My questions are this....do I go after them and make

them prove to me that they have ever paid for a

band....and if so, why was my son's denied. Or...did

they in fact never pay for a band, and in essence led

me on with false hope?

The other glitch is that I work for a hospital...in

fact, the hospital I work for is the #1 Baby Hospital

in the country i.e., they deliver more babies than

any other hospital in the country...and they are BIG

proponents of the BACK to SLEEP Campaign, but nowhere,

in their " Home with Mom " brochures, do they ever warn

of plagiocephaly as a possible outcome of the Back to

Sleep Campaign....and our insurance company is

Principal which doesn't cover their own employee's

kids which I think would be an embarrassment to the

administration if this were to be found out....

I can't imagine that they know this!

I put a lot into my original letter which most people

probably wait to put in for their appeal...since I

already had a lot of ammunition. They waited 3 months

to deny me (apparently they usually deny within a

couple of days)!

Anyway, does anyone have any other info on how banding

corrects bodily function????

I do not plan to rest on my laurels on this one....

what is the process here?

What does a 1st appeal involve? What does a 2nd appeal

involve? What is an external review? And then finally,

when does one call in the lawyers?

I promise that I plan to win this one.

We already paid the $3000 as it was in our child's

best interest to do this in the 4-6 month

window....now, I plan to FIGHT!!!!

All advice is appreciated!

Thank you,

L. Townsend

__________________________________________________