Re: Health America - denied again!

[Guest guest]

:

I am so sorry to hear of your pathetic insurance not coming thru for

you & your family. It sounds like you went in their completely

prepared with every possible document stating the uses of these

bands, etc......I really get so upset reading of everyone's insurance

battles - it is not fair!

Please let us know if you do end up going to the PA Dept. of

Insurance and what happens from there. Good luck if you do.

But on a much happier note: I am so happy to hear of Ben's great

success in his STARband. That is terrific he's now only sleeping in

it & will be officially done in just 2 short weeks! That really is

such great news. I'd like to wish him a happy congradulations!

Debbie Abby's mom DOCGrad

MI

> Hi all,

>

> First, I want to thank everyone who has contributed to the

> information presented on this site. It has been extremely helpful

> for me in preparing my case against Health America and their denial

> of coverage for my son 's treatments for positional

> plagiocephaly.

>

> We were denied coverage, I appealed, and was denied, and then this

> past Tuesday morning I met in front of their " so-called " Member

> Satisfaction Committee to present my case once again. I received a

> letter tonight indicating that they are still upholding their

> original decision because my son's helmet does not meet their

> definition of medical necessity.

>

> Normally, I'm a quiet keep to myself and my family kind of guy,

> tonight; I'm incredibly pissed off.

>

> How I could have won this last appeal is beyond me, as I feel I

could

> not have presented our case any better than I did. Thanks to the

> help I received from this site and other resources, I was extremely

> well prepared, and presented our arguments in a clear, calm, and

> confident manner.

>

> Now my options are to turn to the PA Department of Insurance if I'm

> still not satisfied. Well, of course I'm not satisfied. I'm

pissed,

> and I feel like I've been raped for the $1400.00 bill I have in

front

> of me now.

>

> I'm posting tonight because it feels good to share with people who

> understand.

>

> Health America has not heard the last from me, and I cannot believe

> anyone with a brain in their head could collect a check from that

> company without feeling a sense of guilt for the crap that they're

> dishing out on good people.

>

> I'd love to share the information I gathered and the presentation I

> made to the committee, but since I LOST this round, I'm not sure I

> should as I don't want to muddy the waters for others.

>

> So, after a long wordy post--thanks for listening, I feel a bit

> better now--I'm interested in hearing from others who have had

> experience dealing with someone like the PA Department of

Insurance,

> Bureau of Consumer Services. What are my chances, and what help

can

> I expect to receive from an organization like this?

>

> Thank you!

>

>

> The facts:

>

> * My son is now nearly 12 months old.

> * We've been using the STARband with great success since late

January.

> * Our pediatric neurologist has been a fantastic guy.

> * Ben's now only wearing the helmet at night, and will be done with

> it completely in another two weeks.

> * Presented letter entitled " Letter of Medical Necessity " from the

> Director of Pediatric Neurology at our hospital.

> * Among other things, presented AMA positions, FDA classifications,

> Journal of Pediatrics qoutes, CSHS quotes, all showing that these

> treatments are not cosmetic, are not for appearance only, are

> reconstructive, and are being done to correct developmental

> deformities, improve function, prevent Ben from further

> complications, and ensure his continued good health.

[Guest guest]

Hi ,

I am so sorry to hear that you were denied yet again. You sound like

you were extrememly prepared and presented everything necessary. I

have never battled my insurance company, so I'm afraid I don't have

too much advice to give you. I do know that quite a few members have

taken their appeals to an external review board and have had the

denials overturned. I'm sure someone with more experience will chime

in here.

I'm so glad to hear that Ben has seen wonderful results with his

STARband! Whereabout in PA do you live? I am in Philadelphia, and

my twins also wore a STARband.

Please be sure to let us know how things are going with you, and good

luck!

Niki

Kaylie & Danny (STAR grads)

Phila., PA

> Hi all,

>

> First, I want to thank everyone who has contributed to the

> information presented on this site. It has been extremely helpful

> for me in preparing my case against Health America and their denial

> of coverage for my son 's treatments for positional

> plagiocephaly.

>

> We were denied coverage, I appealed, and was denied, and then this

> past Tuesday morning I met in front of their " so-called " Member

> Satisfaction Committee to present my case once again. I received a

> letter tonight indicating that they are still upholding their

> original decision because my son's helmet does not meet their

> definition of medical necessity.

>

> Normally, I'm a quiet keep to myself and my family kind of guy,

> tonight; I'm incredibly pissed off.

>

> How I could have won this last appeal is beyond me, as I feel I

could

> not have presented our case any better than I did. Thanks to the

> help I received from this site and other resources, I was extremely

> well prepared, and presented our arguments in a clear, calm, and

> confident manner.

>

> Now my options are to turn to the PA Department of Insurance if I'm

> still not satisfied. Well, of course I'm not satisfied. I'm

pissed,

> and I feel like I've been raped for the $1400.00 bill I have in

front

> of me now.

>

> I'm posting tonight because it feels good to share with people who

> understand.

>

> Health America has not heard the last from me, and I cannot believe

> anyone with a brain in their head could collect a check from that

> company without feeling a sense of guilt for the crap that they're

> dishing out on good people.

>

> I'd love to share the information I gathered and the presentation I

> made to the committee, but since I LOST this round, I'm not sure I

> should as I don't want to muddy the waters for others.

>

> So, after a long wordy post--thanks for listening, I feel a bit

> better now--I'm interested in hearing from others who have had

> experience dealing with someone like the PA Department of

Insurance,

> Bureau of Consumer Services. What are my chances, and what help

can

> I expect to receive from an organization like this?

>

> Thank you!

>

>

> The facts:

>

> * My son is now nearly 12 months old.

> * We've been using the STARband with great success since late

January.

> * Our pediatric neurologist has been a fantastic guy.

> * Ben's now only wearing the helmet at night, and will be done with

> it completely in another two weeks.

> * Presented letter entitled " Letter of Medical Necessity " from the

> Director of Pediatric Neurology at our hospital.

> * Among other things, presented AMA positions, FDA classifications,

> Journal of Pediatrics qoutes, CSHS quotes, all showing that these

> treatments are not cosmetic, are not for appearance only, are

> reconstructive, and are being done to correct developmental

> deformities, improve function, prevent Ben from further

> complications, and ensure his continued good health.

[Guest guest]

,

Good for you for fighting the good fight- you may be paving the road for

countless parents down the line! Way to go Dad- can't wait for that post on

them paying too!

' Mom

[Guest guest]

A number of you were kind enough to respond to my original post.

Thank you for your comments and support.

As an update, I filed a formal complaint with the Pennsylvania

Department of Insurance, Bureau of Consumer Services, back on 7/1.

They contacted me today, and an Insurance Investigator has been

assigned to my case.

Needless to say, I'm thrilled for any help I can get.

It does appear however from what I heard today that he will be

investigating whether or not my case was handled according to proper

procedures and so on, and not so much whether the medical judgment

HealthAssurance of PA made was correct or incorrect.

In other words, the so-called specialists at HealthAssurance disagree

with our pediatrician and Pediatric Neurology specialist as to

whether or not treatment was " medically necessary " , and this

investigator will not be addressing that, but more whether or not HA

followed procedures correctly along the way.

As far as I'm concerned, that is a bunch of techno-lawyer

speak there, because that implies the insurance companies can do

whatever the heck they feel like doing as long as they follow some

silly procedures.

But, I'm thinking that any and all pressure I can exert on them is

good.

Nonetheless, I just wanted to share with the group that I haven't

given up the fight, and I'm still at it.

I'll post again as I learn more about what's next for me with the PA

DOI. My investigator is sending HA a letter today on my behalf, and

apparently the company has 15 days to respond to this.

So, look for another post from me then.

Thanks!

- 's (STARband graduate) Dad

> > Hi all,

> >

> > First, I want to thank everyone who has contributed to the

> > information presented on this site. It has been extremely

helpful

> > for me in preparing my case against Health America and their

denial

> > of coverage for my son 's treatments for positional

> > plagiocephaly.

> >

> > We were denied coverage, I appealed, and was denied, and then

this

> > past Tuesday morning I met in front of their " so-called " Member

> > Satisfaction Committee to present my case once again. I received

a

> > letter tonight indicating that they are still upholding their

> > original decision because my son's helmet does not meet their

> > definition of medical necessity.

> >

> > Normally, I'm a quiet keep to myself and my family kind of guy,

> > tonight; I'm incredibly pissed off.

> >

> > How I could have won this last appeal is beyond me, as I feel I

> could

> > not have presented our case any better than I did. Thanks to the

> > help I received from this site and other resources, I was

extremely

> > well prepared, and presented our arguments in a clear, calm, and

> > confident manner.

> >

> > Now my options are to turn to the PA Department of Insurance if

I'm

> > still not satisfied. Well, of course I'm not satisfied. I'm

> pissed,

> > and I feel like I've been raped for the $1400.00 bill I have in

> front

> > of me now.

> >

> > I'm posting tonight because it feels good to share with people

who

> > understand.

> >

> > Health America has not heard the last from me, and I cannot

believe

> > anyone with a brain in their head could collect a check from that

> > company without feeling a sense of guilt for the crap that

they're

> > dishing out on good people.

> >

> > I'd love to share the information I gathered and the presentation

I

> > made to the committee, but since I LOST this round, I'm not sure

I

> > should as I don't want to muddy the waters for others.

> >

> > So, after a long wordy post--thanks for listening, I feel a bit

> > better now--I'm interested in hearing from others who have had

> > experience dealing with someone like the PA Department of

> Insurance,

> > Bureau of Consumer Services. What are my chances, and what help

> can

> > I expect to receive from an organization like this?

> >

> > Thank you!

> >

> >

> > The facts:

> >

> > * My son is now nearly 12 months old.

> > * We've been using the STARband with great success since late

> January.

> > * Our pediatric neurologist has been a fantastic guy.

> > * Ben's now only wearing the helmet at night, and will be done

with

> > it completely in another two weeks.

> > * Presented letter entitled " Letter of Medical Necessity " from

the

> > Director of Pediatric Neurology at our hospital.

> > * Among other things, presented AMA positions, FDA

classifications,

> > Journal of Pediatrics qoutes, CSHS quotes, all showing that these

> > treatments are not cosmetic, are not for appearance only, are

> > reconstructive, and are being done to correct developmental

> > deformities, improve function, prevent Ben from further

> > complications, and ensure his continued good health.

[Guest guest]

Way to fight !

I really hope Health America will feel pressured by this & know you

won't stop fighting for what they owe you!

Please keep us posted on it.....hope to see a " Health America Paid "

post from you soon.

Best of luck

Debbie Abby's mom DOCgrad

MI

> > :

> >

> > I am so sorry to hear of your pathetic insurance not coming thru

> for

> > you & your family. It sounds like you went in their completely

> > prepared with every possible document stating the uses of these

> > bands, etc......I really get so upset reading of everyone's

> insurance

> > battles - it is not fair!

> >

> > Please let us know if you do end up going to the PA Dept. of

> > Insurance and what happens from there. Good luck if you do.

> >

> > But on a much happier note: I am so happy to hear of Ben's great

> > success in his STARband. That is terrific he's now only sleeping

> in

> > it & will be officially done in just 2 short weeks! That really

is

> > such great news. I'd like to wish him a happy congradulations!

> >

> > Debbie Abby's mom DOCGrad

> > MI

> >

> >

> > --- In Plagiocephaly@y..., " jphillippy " <john.phillippy@g...>

wrote:

> > > Hi all,

> > >

> > > First, I want to thank everyone who has contributed to the

> > > information presented on this site. It has been extremely

> helpful

> > > for me in preparing my case against Health America and their

> denial

> > > of coverage for my son 's treatments for positional

> > > plagiocephaly.

> > >

> > > We were denied coverage, I appealed, and was denied, and then

> this

> > > past Tuesday morning I met in front of their " so-called " Member

> > > Satisfaction Committee to present my case once again. I

received

> a

> > > letter tonight indicating that they are still upholding their

> > > original decision because my son's helmet does not meet their

> > > definition of medical necessity.

> > >

> > > Normally, I'm a quiet keep to myself and my family kind of guy,

> > > tonight; I'm incredibly pissed off.

> > >

> > > How I could have won this last appeal is beyond me, as I feel I

> > could

> > > not have presented our case any better than I did. Thanks to

the

> > > help I received from this site and other resources, I was

> extremely

> > > well prepared, and presented our arguments in a clear, calm,

and

> > > confident manner.

> > >

> > > Now my options are to turn to the PA Department of Insurance if

> I'm

> > > still not satisfied. Well, of course I'm not satisfied. I'm

> > pissed,

> > > and I feel like I've been raped for the $1400.00 bill I have in

> > front

> > > of me now.

> > >

> > > I'm posting tonight because it feels good to share with people

> who

> > > understand.

> > >

> > > Health America has not heard the last from me, and I cannot

> believe

> > > anyone with a brain in their head could collect a check from

that

> > > company without feeling a sense of guilt for the crap that

> they're

> > > dishing out on good people.

> > >

> > > I'd love to share the information I gathered and the

presentation

> I

> > > made to the committee, but since I LOST this round, I'm not

sure

> I

> > > should as I don't want to muddy the waters for others.

> > >

> > > So, after a long wordy post--thanks for listening, I feel a bit

> > > better now--I'm interested in hearing from others who have had

> > > experience dealing with someone like the PA Department of

> > Insurance,

> > > Bureau of Consumer Services. What are my chances, and what

help

> > can

> > > I expect to receive from an organization like this?

> > >

> > > Thank you!

> > >

> > >

> > > The facts:

> > >

> > > * My son is now nearly 12 months old.

> > > * We've been using the STARband with great success since late

> > January.

> > > * Our pediatric neurologist has been a fantastic guy.

> > > * Ben's now only wearing the helmet at night, and will be done

> with

> > > it completely in another two weeks.

> > > * Presented letter entitled " Letter of Medical Necessity " from

> the

> > > Director of Pediatric Neurology at our hospital.

> > > * Among other things, presented AMA positions, FDA

> classifications,

> > > Journal of Pediatrics qoutes, CSHS quotes, all showing that

these

> > > treatments are not cosmetic, are not for appearance only, are

> > > reconstructive, and are being done to correct developmental

> > > deformities, improve function, prevent Ben from further

> > > complications, and ensure his continued good health.

[Guest guest]

Hey where do you live in Pa???

Beck

[Guest guest]

,

Here's hoping that the investigation shows that your insurnace didn't

follow proper protocol and they have to cover 's band!! Good

luck and keeping fighting!

Niki

Kaylie & Danny (STAR grads)

Phila., PA

> > :

> >

> > I am so sorry to hear of your pathetic insurance not coming thru

> for

> > you & your family. It sounds like you went in their completely

> > prepared with every possible document stating the uses of these

> > bands, etc......I really get so upset reading of everyone's

> insurance

> > battles - it is not fair!

> >

> > Please let us know if you do end up going to the PA Dept. of

> > Insurance and what happens from there. Good luck if you do.

> >

> > But on a much happier note: I am so happy to hear of Ben's great

> > success in his STARband. That is terrific he's now only sleeping

> in

> > it & will be officially done in just 2 short weeks! That really

is

> > such great news. I'd like to wish him a happy congradulations!

> >

> > Debbie Abby's mom DOCGrad

> > MI

> >

> >

> > --- In Plagiocephaly@y..., " jphillippy " <john.phillippy@g...>

wrote:

> > > Hi all,

> > >

> > > First, I want to thank everyone who has contributed to the

> > > information presented on this site. It has been extremely

> helpful

> > > for me in preparing my case against Health America and their

> denial

> > > of coverage for my son 's treatments for positional

> > > plagiocephaly.

> > >

> > > We were denied coverage, I appealed, and was denied, and then

> this

> > > past Tuesday morning I met in front of their " so-called " Member

> > > Satisfaction Committee to present my case once again. I

received

> a

> > > letter tonight indicating that they are still upholding their

> > > original decision because my son's helmet does not meet their

> > > definition of medical necessity.

> > >

> > > Normally, I'm a quiet keep to myself and my family kind of guy,

> > > tonight; I'm incredibly pissed off.

> > >

> > > How I could have won this last appeal is beyond me, as I feel I

> > could

> > > not have presented our case any better than I did. Thanks to

the

> > > help I received from this site and other resources, I was

> extremely

> > > well prepared, and presented our arguments in a clear, calm,

and

> > > confident manner.

> > >

> > > Now my options are to turn to the PA Department of Insurance if

> I'm

> > > still not satisfied. Well, of course I'm not satisfied. I'm

> > pissed,

> > > and I feel like I've been raped for the $1400.00 bill I have in

> > front

> > > of me now.

> > >

> > > I'm posting tonight because it feels good to share with people

> who

> > > understand.

> > >

> > > Health America has not heard the last from me, and I cannot

> believe

> > > anyone with a brain in their head could collect a check from

that

> > > company without feeling a sense of guilt for the crap that

> they're

> > > dishing out on good people.

> > >

> > > I'd love to share the information I gathered and the

presentation

> I

> > > made to the committee, but since I LOST this round, I'm not

sure

> I

> > > should as I don't want to muddy the waters for others.

> > >

> > > So, after a long wordy post--thanks for listening, I feel a bit

> > > better now--I'm interested in hearing from others who have had

> > > experience dealing with someone like the PA Department of

> > Insurance,

> > > Bureau of Consumer Services. What are my chances, and what

help

> > can

> > > I expect to receive from an organization like this?

> > >

> > > Thank you!

> > >

> > >

> > > The facts:

> > >

> > > * My son is now nearly 12 months old.

> > > * We've been using the STARband with great success since late

> > January.

> > > * Our pediatric neurologist has been a fantastic guy.

> > > * Ben's now only wearing the helmet at night, and will be done

> with

> > > it completely in another two weeks.

> > > * Presented letter entitled " Letter of Medical Necessity " from

> the

> > > Director of Pediatric Neurology at our hospital.

> > > * Among other things, presented AMA positions, FDA

> classifications,

> > > Journal of Pediatrics qoutes, CSHS quotes, all showing that

these

> > > treatments are not cosmetic, are not for appearance only, are

> > > reconstructive, and are being done to correct developmental

> > > deformities, improve function, prevent Ben from further

> > > complications, and ensure his continued good health.

[Guest guest]

Hi

We were in a similar situation. We had an External Review Board take our case

after all appeals were denied. The good thing about this was that they could

review the medical necessity AND whether or not Healthcare Oklahoma had

followed the correct procedures. Fortunately for me the helmet was found to

be medically necessary and Healthcare Oklahoma was found to have NOT followed

correct procedures.

Best of luck with that and thanks for the update!

Marci (Mom to )

Oklahoma