Re: Insurance Denial!

[Guest guest]

--- robyn1767 <robyn1767@...> wrote:

> Well, we received our first denial letter today and

> I'm looking for

> some suggestions. Just a brief (I hope) overview of

> our

> situation...We went to our ped about 5-6 weeks ago

> and asked him

> about getting a referral for a helmet. He had next

> to no information

> on helmets and had obviously never referred anyone

> for one before.

> Hard to believe when I'm told this condition is

> being seen more and

> more these days because of the " back to sleep "

> campaign. Anyway, he

> did end up getting us a referral to the Cranial

> Facial Clinic at Loma

> Hospital. By this time, my son was about 2

> weeks away from his

> 1st birthday. When we called the clinic, the nurse

> told me that they

> really don't do the helmets on children over a year

> and basically

> said that she was going to tell our ped. that it was

> too late for

> them to do anything. I called her back and said I

> would like to at

> least have him seen and she ended up saying they

> would see him, but

> could not see him until the first week of June,

> about 6 weeks away.

> At this point, I started researching on the internet

> and found

> Cranial Technologies and the DocBand. We made an

> appointment for the

> following week with a ped. neurosurgeon that refers

> patients for the

> DocBand, got the referral and our son was casted 5

> days later. We of

> course did this without insurance authorization, and

> just received a

> letter of denial because we went " out of network. "

> Apparently they

> would prefer we had waited another 6 weeks to be

> seen by Loma

> just so they could tell us it was too late for them

> to do anything.

> Since time was critical, we got things moving,

> knowing that we may

> end up having to pay for this ourselves. It is very

> frustrating,

> especially considering that if our pediatrician had

> been more

> knowledgeable about treatment options, we could have

> started this

> whole process when he was much younger and may have

> had time to

> actually wait for an authorization.

>

> Well, as I said, I'm looking for anyone who may have

> had a similar

> experience who might be able to offer some

> suggestions. By the way,

> we have BlueCross California Care, which is the Blue

> Cross HMO. Our

> medical group was the one that denied us the

> referral, because they

> had already referred us to Loma (for all the

> good that was

> going to do). Apparently since we are part of an

> HMO, the medical

> group's review board is the one that makes the

> decision on whether or

> not to give us a referral. I called Blue Cross and

> they said we need

> to send them a letter telling them why we feel this

> should not have

> been denied and then they have 30 days to review it

> and get back to

> us and our medical group. Any suggestions?

>

> Robyn

>

>

My daughter , is 5 mo's and we went ahead and got

her DOC band after BCBS of Oregon - PPO denied our

preauthorization. They denied it on the basis that is

wasn't " medically necessary. " I have since sent an

appeal letter and am waiting for their response. CT

was really helpful and provided alot of information

such as articles and research papers stating that the

band is medically necessary. I also enclosed our

neurosurgeon's letters of medical necessity. One

interesting piece of info that CT gave me was a copy

of a letter from Blue Shield California to

Bitting of CT that was written in 2001 stating that

they cover the DOC Band up to $2,200. I enclosed that

with my denial letter. I was so stressed about

writing my denial letter...where to begin? If you go

into the Plagiocephaly Group " Files " you'll find an

insurance info file, which has copies of great appeal

letters that other parents have shared as well as some

great research papers. This really helped me a great

deal with my appeal letter. There's also a section in

the Plagiocephaly Group that I think is under

" database " or " data " with a list of parents and

insurers who have covered the headband/helmets, what

they paid and what each child's circumstances were.

This section is where I found that Blue Shield of

North Carolina paid %100 for a DOC Band and the

child's circumstances were the same as mine! All this

should be good ammo for your appeal letter. Good luck

and I'll let you know the results of my appeal. P.S.

There's also some excellent information on how you to

go about with your appeal letter at www.plagiocephaly.org.

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