Re: Denial letter

[Guest guest]

Thanks Marci!! I hope not either. The lady at CT had said that Guardian a lot of times does end up paying..but not the whole amount. They usually end up paying a percentage of $2000 instead of $3000...which something is better than nothing..but it would be a lot better if they at least paid a percentage of the whole amount. But first i better concentrate on them paying at all..lol.

Thanks,

In a message dated 7/25/2002 9:30:13 AM Pacific Daylight Time, marcisch@... writes:

,

The DOCband should not be considered experiemental. It is FDA approved. CT should have all the documentation necessary to fight that denial reason. I think it would be hard for Anthem to get that denial reason to stick. It seems that denial based on not medically necessary is harder to fight. Hopefully Guardian won't cause you any trouble at all.

Marci (Mom to )

Oklahoma

[Guest guest]

,

The DOCband should not be considered experiemental. It is FDA approved. CT

should have all the documentation necessary to fight that denial reason. I think

it would be hard for Anthem to get that denial reason to stick. It seems that

denial based on not medically necessary is harder to fight. Hopefully Guardian

won't cause you any trouble at all.

Marci (Mom to )

Oklahoma

[Guest guest]

,

There is tons of information out there to argue the experimental excuse the

insurance companies give for denial. That was one of our reasons and we

bombarded them with material. Let me paste a portion of our last appeal

letter for you - if it comes down to it, I can email our entire letter to

you so that you have all the specific references, but this will show you

that there is good documentation out there.

Gail, Sam and Sara's mom, DOC grads

Here's part of our letter...

CIGNA's arbitrary refusal to accept the findings of the FDA and two separate

studies as sufficient support to prove the effectiveness of the DOC band is

astounding. However, as it appears that CIGNA will require an unreasonable

amount of documentation to accept DOC banding as effective treatment for

plagiocephaly. Therefore, allow me to reference the following:

? In the article " Abnormal Head shape in Infants " by Deirdre Marshall, MD et

al, Sterling Clarren, of the University of Washington states " .the

effectiveness of helmet therapy decreases if begun later . and if a child

presents beyond a year and a half of age, it cannot be expected to

completely correct the problem. " Or putting it another way, using a helmet

while a child is in its first year of life can completely correct the head

shape.

? Guidelines were established at the 1997 Craniosynostosis and Skull Molding

Symposium as to the " best " method for the treatment of plagiocephaly. To

summarize: " If repositioning is unsuccessful or if the initial deformity is

too severe, or if the child is too old for repositioning to be effective

(5-6 months) Orthotic Management should be considered the next logical

alternative! "

? A position paper endorsed by the Section of Plastic Surgery of the

American Academy of Pediatrics, The American Society of Cranio-facial

Surgeons, and the American Association of Pediatric Neurosurgeons states

that infants with deformational plagiocephaly usually respond well to the

use of " skull molding caps " .

? Dr. Ann Flannery, Department of Surgery/Section of Neurosurgery at the

Medical College of Georgia has stated: " Babies who are severely effected

[by plagiocephaly] can also be placed in a molding helmet or band. "

? The Cedars-Sinai Medical Center, Department of Pediatrics position

relating to the treatment of plagiocephaly and torticollis states:

" management for infants who do not make progress with exercise alone, or for

infants with moderate to severe plagiocephaly still present at six months

involves the use of a corrective helmet . the results have been excellent "

? Dr. Deidre Marshall of Miami Children's Hospital states: " Insurance

companies and HMO's must realize that the prompt authorization of requests

for helmet therapy in children requiring them will, in the long run, be much

more cost effective than denying or postponing authorization for a helmet

and then having to fund a major intracranial surgical procedure "

Denial letter

> Well I just got the denial letter from Anthem. (Which i knew it was

denied...and i'm going to be using Guardian now anyway..so hopefully they'll

pay)...but the reason it was denied was b/c they consider it experimental

and investigative..so they won't pay for that. What can you do to overturn

that decision? I'm not even going to try..since i'm going to have Guardian

now..but in case they deny me for the same thing? How do you prove it's not

experimental? (Trisha, i'm still looking through all your

stuff..lol..thanks!!)

>

>

> Mom to

>

>

> For more plagio info

[Guest guest]

Hi ,

There's a lawsuit going on against BCBS in Chicago

because some families were denied helmet therapy on

the same basis. The argument is that it's not

experimental because it has been approved by the FDA.

CT can provide you with the paperwork from the FDA.

, 's mom

Southern California

--- Av@... wrote:

> Well I just got the denial letter from Anthem.

> (Which i knew it was denied...and i'm going to be

> using Guardian now anyway..so hopefully they'll

> pay)...but the reason it was denied was b/c they

> consider it experimental and investigative..so they

> won't pay for that. What can you do to overturn

> that decision? I'm not even going to try..since i'm

> going to have Guardian now..but in case they deny me

> for the same thing? How do you prove it's not

> experimental? (Trisha, i'm still looking through

> all your stuff..lol..thanks!!)

>

>

> Mom to

>

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