Need help gathering insurance info.

[Guest guest]

Hello,

I just found out this morning that the external independent reviewer

upheld our insurance company's stance that the the DOC band isn't

medically necessary on the grounds that we cannot " prove " our daughter

will have a functional deficit without treatment. If we want to

continue to pursue, our next step is to contact the state department

of insurance (our insurance company is Unicare HMO and we live in

Illinois). Has anyone pursued this far? Any suggestions? Our last

appeal letter was 8 pages, including 2 letters from drs stating

medical necessity (pediatrician and pediatric plastic surgeon) and

numerous references cited. I don't understand how this same treatment

can be deemed medically necessary by some insurance companies and not

by others. If your insurance company covers it, could you please

contact me with your insurance company and state so I can forward that

information to the Dept. of Insurance.

Thank you!

Marie

[Guest guest]

Marie, we're one step behind you -- also Unicare in Illinois, but

we're just getting ready to submit our external appeal. I posted a

question a couple other places to see WHERE there is data on proving

the bad outcomes, but I'm not too hopeful.

Did you reference the Cook County States Attorney's lawsuit against

Blue Cross on this issue?

http://www.statesattorney.org/pressbacksleep01.htm

It looks like there's some hope even if we have to wait until after

the fact ...

Anyone else with any ideas on peer-reviewed studies of the

consequences of inaction?

CL, father of Drew, 7mos.

>

> Hello,

> I just found out this morning that the external independent reviewer

> upheld our insurance company's stance that the the DOC band isn't

> medically necessary on the grounds that we cannot " prove " our daughter

> will have a functional deficit without treatment. If we want to

> continue to pursue, our next step is to contact the state department

> of insurance (our insurance company is Unicare HMO and we live in

> Illinois). Has anyone pursued this far? Any suggestions? Our last

> appeal letter was 8 pages, including 2 letters from drs stating

> medical necessity (pediatrician and pediatric plastic surgeon) and

> numerous references cited. I don't understand how this same treatment

> can be deemed medically necessary by some insurance companies and not

> by others. If your insurance company covers it, could you please

> contact me with your insurance company and state so I can forward that

> information to the Dept. of Insurance.

> Thank you!

> Marie

>