Guest guest Posted May 29, 2002 Report Share Posted May 29, 2002 I just read Trisha's last post, and about all I can do right now is laugh (not at you, Trisha - at the imbeciles at Cigna). Cigna is messing with some tough Texans!!! We just received our next denial letter and I'm pretty angry about it, though not at all surprised. I think the medical director got his license from a grab bag at Sears! Anyway, let me paraphrase their most recent reasons for denial, and I'm not being sarcastic at all. 1. The AMA is incorrect in their definitions of cosmetic vs. reconstructive. 2. The FDA's classification of the DOC band as a category II neurology device is not valid and DOC bands are experimental. 3. The prescription for DOC banding by a participating physician who considers treatment medically necessary "does not de facto determine" medical necessity (only when convenient for Cigna). Did I miss something? Is today April Fools Day? They "regret that this response is not more favorable". They don't know the meaning of "regret" yet! I sure hope I'm beginning to sound like you, Trisha. They'll regret the day they ever denied payment. Here's another gripe...I have requested many times that they assign a grievance coordinator or customer advocate to us so that we can actually talk to someone that might know something about the appeals process, but they won't do it. They keep telling me that they save that for escalated issues. When does an issue become escalated? They tell us that we should call the member services phone number listed on our insurance card and they "will be happy to assist" us. Those people don't have a clue and they can't even transfer the call to someone in appeals. All they can do is put a note in the computer that we called looking for information. They are more classified than the FBI! Things just don't make sense. This is the same insurance company that reimbursed us $10,000 for in vitro fertilization and sent a huge packet of information to me about how to have healthy babies, yet they failed to mention that carrying twins full term could cause in utero constraint that leads to tort and plagio, and they definitely don't want to pay to correct the problem in these miracle babies. It makes me sad that such ignorant people can have such a strong influence on medical decisions for our precious little ones. Well, I've rambled on enough and I need to refocus my energy on the next appeal. I'll keep you posted. Gail, Sam and Sara (DOC grads) P.S. Sam had his exit cast today and he was awesome! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 29, 2002 Report Share Posted May 29, 2002 Holy Cow Gail!!!!!!! WOW - what a crock of crap! So now Cigna is going to say the AMA is incorrect, the FDA's classification is not valid, the DOCband IS experimental, and the Dr. who wrote the RX is also wrong????? Wow, I can feel your blood pressure rising all the way up to MI right now! My blood pressure is up right now & I'm not the person paying for 2 bands!!!!!!!!! Good grief. You just keep fighting, I don't wanna be Cigna right now dealing with BOTH you & Trisha, YIKES! On a much happier note though, glad Sam's exit casting is done & he did so well. Ohhhh, all I can say is good luck with stupid Cigna. Geez.... Debbie Abby's mom dOCGrad MI > I just read Trisha's last post, and about all I can do right now is laugh (not at you, Trisha - at the imbeciles at Cigna). Cigna is messing with some tough Texans!!! We just received our next denial letter and I'm pretty angry about it, though not at all surprised. I think the medical director got his license from a grab bag at Sears! Anyway, let me paraphrase their most recent reasons for denial, and I'm not being sarcastic at all. > 1. The AMA is incorrect in their definitions of cosmetic vs. reconstructive. > 2. The FDA's classification of the DOC band as a category II neurology device is not valid and DOC bands are experimental. > 3. The prescription for DOC banding by a participating physician who considers treatment medically necessary " does not de facto determine " medical necessity (only when convenient for Cigna). > Did I miss something? Is today April Fools Day? They " regret that this response is not more favorable " . They don't know the meaning of " regret " yet! I sure hope I'm beginning to sound like you, Trisha. They'll regret the day they ever denied payment. > > Here's another gripe...I have requested many times that they assign a grievance coordinator or customer advocate to us so that we can actually talk to someone that might know something about the appeals process, but they won't do it. They keep telling me that they save that for escalated issues. When does an issue become escalated? They tell us that we should call the member services phone number listed on our insurance card and they " will be happy to assist " us. Those people don't have a clue and they can't even transfer the call to someone in appeals. All they can do is put a note in the computer that we called looking for information. They are more classified than the FBI! > > Things just don't make sense. This is the same insurance company that reimbursed us $10,000 for in vitro fertilization and sent a huge packet of information to me about how to have healthy babies, yet they failed to mention that carrying twins full term could cause in utero constraint that leads to tort and plagio, and they definitely don't want to pay to correct the problem in these miracle babies. It makes me sad that such ignorant people can have such a strong influence on medical decisions for our precious little ones. Well, I've rambled on enough and I need to refocus my energy on the next appeal. I'll keep you posted. > > Gail, Sam and Sara (DOC grads) > > P.S. Sam had his exit cast today and he was awesome! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 29, 2002 Report Share Posted May 29, 2002 Hey, I think my husband is jumping on the band wagon and is finally as passionate about this as I am. He just wrote and awesome letter that we are sending back to Cigna today. He is demanding that they provide references to a journal they mentioned that classifies plagiocephaly as "simply a cosmetic problem". We want to see for ourselves if this journal exists and if there is something in the article that might be to our benefit. They also mention "other published data" without bothering to give us a source. Why wouldn't they provide the reference in the first place? Are they hiding something? He's also asking for information on the "independent technology review agency" that determined that the data that was sufficient for the FDA to classify DOC bands was not sufficient for Cigna. We want to know who they are and who they work for and if they have been compensated by Cigna for their services. Are we correct to assume that we have a right to this information? After all, we provided all the documentation and study information to back up our claims in our appeal, right? Shouldn't they do the same? Frustrated but NOT giving up, Gail, Sam and Sara's mom, DOC grads Re: Cigna denied us - AGAIN! Holy Cow Gail!!!!!!!WOW - what a crock of crap! So now Cigna is going to say the AMA is incorrect, the FDA's classification is not valid, the DOCband IS experimental, and the Dr. who wrote the RX is also wrong?????Wow, I can feel your blood pressure rising all the way up to MI right now! My blood pressure is up right now & I'm not the person paying for 2 bands!!!!!!!!! Good grief. You just keep fighting, I don't wanna be Cigna right now dealing with BOTH you & Trisha, YIKES!On a much happier note though, glad Sam's exit casting is done & he did so well.Ohhhh, all I can say is good luck with stupid Cigna. Geez....Debbie Abby's mom dOCGradMI Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 29, 2002 Report Share Posted May 29, 2002 Gail, There is a lady here I got in contact w/ through CT...and she did this and they considered it an appeal!!! Go Figure...are ya'll going w/that attorney??? I just talked to him...he said he had been talking to your husband but that he hadnt talked to you ( I told him I knew ya) What is your take on this?? I am going to talk to Jon tonight about it...sigh....Trisha -----Original Message-----From: Gail [mailto:momofivftwins@...]Sent: Wednesday, May 29, 2002 3:22 PMPlagiocephaly Subject: Re: Re: Cigna denied us - AGAIN! Hey, I think my husband is jumping on the band wagon and is finally as passionate about this as I am. He just wrote and awesome letter that we are sending back to Cigna today. He is demanding that they provide references to a journal they mentioned that classifies plagiocephaly as "simply a cosmetic problem". We want to see for ourselves if this journal exists and if there is something in the article that might be to our benefit. They also mention "other published data" without bothering to give us a source. Why wouldn't they provide the reference in the first place? Are they hiding something? He's also asking for information on the "independent technology review agency" that determined that the data that was sufficient for the FDA to classify DOC bands was not sufficient for Cigna. We want to know who they are and who they work for and if they have been compensated by Cigna for their services. Are we correct to assume that we have a right to this information? After all, we provided all the documentation and study information to back up our claims in our appeal, right? Shouldn't they do the same? Frustrated but NOT giving up, Gail, Sam and Sara's mom, DOC grads Re: Cigna denied us - AGAIN! Holy Cow Gail!!!!!!!WOW - what a crock of crap! So now Cigna is going to say the AMA is incorrect, the FDA's classification is not valid, the DOCband IS experimental, and the Dr. who wrote the RX is also wrong?????Wow, I can feel your blood pressure rising all the way up to MI right now! My blood pressure is up right now & I'm not the person paying for 2 bands!!!!!!!!! Good grief. You just keep fighting, I don't wanna be Cigna right now dealing with BOTH you & Trisha, YIKES!On a much happier note though, glad Sam's exit casting is done & he did so well.Ohhhh, all I can say is good luck with stupid Cigna. Geez....Debbie Abby's mom dOCGradMIFor more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 30, 2002 Report Share Posted May 30, 2002 ---Gail this is ridiculous!!!!!!!!They just keep finding more stuff to say about denying people. Let me know if you would like to see a copy of my appeal letter to cigna!!! Why do they cover the band for some???????????????Hugs~ In Plagiocephaly@y..., " Gail " <momofivftwins@a...> wrote: > I just read Trisha's last post, and about all I can do right now is laugh (not at you, Trisha - at the imbeciles at Cigna). Cigna is messing with some tough Texans!!! We just received our next denial letter and I'm pretty angry about it, though not at all surprised. I think the medical director got his license from a grab bag at Sears! Anyway, let me paraphrase their most recent reasons for denial, and I'm not being sarcastic at all. > 1. The AMA is incorrect in their definitions of cosmetic vs. reconstructive. > 2. The FDA's classification of the DOC band as a category II neurology device is not valid and DOC bands are experimental. > 3. The prescription for DOC banding by a participating physician who considers treatment medically necessary " does not de facto determine " medical necessity (only when convenient for Cigna). > Did I miss something? Is today April Fools Day? They " regret that this response is not more favorable " . They don't know the meaning of " regret " yet! I sure hope I'm beginning to sound like you, Trisha. They'll regret the day they ever denied payment. > > Here's another gripe...I have requested many times that they assign a grievance coordinator or customer advocate to us so that we can actually talk to someone that might know something about the appeals process, but they won't do it. They keep telling me that they save that for escalated issues. When does an issue become escalated? They tell us that we should call the member services phone number listed on our insurance card and they " will be happy to assist " us. Those people don't have a clue and they can't even transfer the call to someone in appeals. All they can do is put a note in the computer that we called looking for information. They are more classified than the FBI! > > Things just don't make sense. This is the same insurance company that reimbursed us $10,000 for in vitro fertilization and sent a huge packet of information to me about how to have healthy babies, yet they failed to mention that carrying twins full term could cause in utero constraint that leads to tort and plagio, and they definitely don't want to pay to correct the problem in these miracle babies. It makes me sad that such ignorant people can have such a strong influence on medical decisions for our precious little ones. Well, I've rambled on enough and I need to refocus my energy on the next appeal. I'll keep you posted. > > Gail, Sam and Sara (DOC grads) > > P.S. Sam had his exit cast today and he was awesome! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 30, 2002 Report Share Posted May 30, 2002 It is ridiculous, isn't it!!! My husband called a children's hospital in Fort Worth asking them to find the journal that Cigna mentioned in their denial letter, but didn't bother to reference. A wonderful lady over there spent half a day looking and came up blank. She sent a 61 page fax back to us with other helpful information, though. Do you think it's possible that they made up the journal just for our denial? I wouldn't put anything past them. I wish I knew why they cover some and not others. I'm about ready to send them a list of names of all the babies who they have paid for, but I don't think that's cool. I talked to one of my neighbors and her 4 month old has severe plagio, and her ped will send her to a specialist at 6 months, but she has our exact insurance. I've already got her working towards getting Cigna to pay. Well, this is just a collection of my random thoughts right now. I'll keep you posted. , if you can, please email me a copy of your letter to momofivftwins@.... I've got a whole file of sample letters to Cigna, but another can't hurt, and yours might be the missing link! Thanks for the words of support, Gail Re: Cigna denied us - AGAIN! ---Gail this is ridiculous!!!!!!!!They just keep finding more stuff to say about denying people. Let me know if you would like to see a copy of my appeal letter to cigna!!! Why do they cover the band for some???????????????Hugs~ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 30, 2002 Report Share Posted May 30, 2002 Hi Gail, I must have missed part of this discussion. What's the name of the Journal that Cigna mentioned? I'll run at check at work. Regards,<!-- M. , Ph.D. Webworks & the University of IowaLearn more at http://www.KM.net.See the sites at http://www.Webworks.com!--> -----Original Message-----From: Gail [mailto:momofivftwins@...]Sent: Thursday, May 30, 2002 17:20Plagiocephaly Subject: Re: Re: Cigna denied us - AGAIN! It is ridiculous, isn't it!!! My husband called a children's hospital in Fort Worth asking them to find the journal that Cigna mentioned in their denial letter, but didn't bother to reference. A wonderful lady over there spent half a day looking and came up blank. She sent a 61 page fax back to us with other helpful information, though. Do you think it's possible that they made up the journal just for our denial? I wouldn't put anything past them. I wish I knew why they cover some and not others. I'm about ready to send them a list of names of all the babies who they have paid for, but I don't think that's cool. I talked to one of my neighbors and her 4 month old has severe plagio, and her ped will send her to a specialist at 6 months, but she has our exact insurance. I've already got her working towards getting Cigna to pay. Well, this is just a collection of my random thoughts right now. I'll keep you posted. <snip> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 30, 2002 Report Share Posted May 30, 2002 In a message dated 5/30/2002 5:21:47 PM Central Daylight Time, momofivftwins@... writes: She sent a 61 page fax back to us with other helpful information, though. Do you think it's possible that they made up the journal just for our denial? I wouldn't Would love to see this info! Beck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 31, 2002 Report Share Posted May 31, 2002 good suggestions!1 Beck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 31, 2002 Report Share Posted May 31, 2002 go hubby go hubby go hubby! beck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 31, 2002 Report Share Posted May 31, 2002 Hey , Thanks. We argued that DOC is a reconstructive procedure for a skull deformation, and this is what they responded with. Though the appeal argues that treatment to correct an abnormal headshape is not cosmetic, a recent review of this subject in Pediatric Clinics of North America classifies occipital plagiocephaly as "simply a cosmetic problem", finds no evidence for secondary functional problems, and indicates that the goal of treatment is "improving cosmesis". They didn't provide any info on this journal like issue, date, volume, author, or anything else. If you can find it I would be grateful. Gail RE: Re: Cigna denied us - AGAIN! Hi Gail, I must have missed part of this discussion. What's the name of the Journal that Cigna mentioned? I'll run at check at work. Regards,<!-- M. , Ph.D. Webworks & the University of IowaLearn more at http://www.KM.net.See the sites at http://www.Webworks.com! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 31, 2002 Report Share Posted May 31, 2002 Have you considered this: Since it is defined as the occipital region, tthis means that the "collapsed", flat part of the skull is adding undue pressure to the occipital lobe of the brain, which directly controls vision and gait (ones ability to "carry" themselves, hold their head up on their own, etc.) Consider seeing an opthalmologist (This is covered under most insurances). Most likely your child's vision is not YET affected, but he/she should be able to provide a letter of urgency. This letter could discuss / indicate that long-term pressure against the occipital lobe could most definitely lead to vision and gait disturbances that once the child's brain has matured, would most definitely be permanent and not correctable. Good luck! Be strong, yet courteous. E-mail photos of your son with his "round head" on his birth date, as well as recent photos to prove that it is reconstructive, and also add a personal touch. Ask to speak with a supervisor. Ask the supervisor if they are a parent. If they are not, ask to speak with another super until you get one that is. Then say, "Think about your child when they were this age. Believe me, no parent would want a huge, uncomfortable helmet on their child's head for 23 hours a day, for 5 months unless it was absolutely necessary. If he doesn't get this helmet, the only means of correction would be a full craniectomy. That is a $30,000 surgery, and involves risks of stroke, brain bleeds, and brain damage. However, my son has to have his head corrected to ensure that he will be able to see, and if this is the only option available under my insurance, than I guess those are risks I'll have to take!!!!" RE: Re: Cigna denied us - AGAIN! Hi Gail, I must have missed part of this discussion. What's the name of the Journal that Cigna mentioned? I'll run at check at work. Regards,<!-- M. , Ph.D. Webworks & the University of IowaLearn more at http://www.KM.net.See the sites at http://www.Webworks.com!For more plagio info Quote Link to comment Share on other sites More sharing options...
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