Re: Helmets/Medical necessity with Insurance

[Guest guest]

Hi -

My insurance is still in process of reviewing our claim and did

require a letter of medical necessity. They didn't specify any

additional records or recommendations be sent as well though. I am

assuming that if they deny, or don't pay the full amount they

should, I would appeal with that information. I did include some

measurements and other info from Cranial Tech though, just to cover

everything I could for the initial claim.

We saw a craniofacial surgeon who wrote the script for the band and

apparently he churns out letters of medical necessity all the time.

I just asked his assistant for one. It was a 2-page letter that

detailed the condition and specified all the possible problems that

could arise if it is left untreated. I just glanced at it again and

realized it doesn't say anything specific about my son's

torticollis, but that the plagio was probably brought on by

his " position in the uterus and postnatal period. " I guess if we

have a problem with insurance, I will revisit the torticollis as the

root to the problem. But again, the letter is very detailed and

breaks down how the skull works and how assymetry develops, and that

a DOC band is the best way to go to treat it. I'm not sure how

pediatricians would put together a letter of medical necessity if

they don't do them on a regular basis. I personally feel a lot

better that my letter came from a specialist that might add more

detail and knowledge to the letter. Of course, we'll see if it

worked for us in another week or so (I know we have coverage for a

band, and they should cover 75% of it, however I'm worried that they

might not want to recognize that it cost $3000 and will therefore

pay a lot less than it actually cost). We shall see!

Oh, also, I've heard of letters stating the steps that were taken to

correct the problem naturally, i.e. aggressive repositioning. So

that might be something else you would want them to add. Now that I

think about it, our letter is really cookie-cutter like, not really

super specific to my son's situation (cause it doesn't mention repo

either). But I guess I'll worry about that later if it doesn't do

the trick with the insurance company!

Good luck!

Jake-18m (tort resolved/rt plagio/DOCBand 2/11/08)

Jordan-4

>

> Hi all,

> 1st off thanks for all of your comments on the helmet cost

> question I asked yesterday, you're all so helpful. Although I am

> not sure if Kaylie will need the helmet yet, I went ahead &

checked

> with our insurance & they said it would be covered if it were " of

> medical necessity " . They said our physician will need to send

> records & any recommendation to their medical review dept.

>

> Does this sound familiar to anyone?

>

> And what is the wording from Kaylie's physician that needs to be

> stated to proclaim medical necessity?

>

> We believe she has torticollis from birth, maybe a bit of plagio &

> now her face is asymmetrical.

>

> Thanks!

>

> & Kaylie

>

[Guest guest]

Thanks for all of the info. I just hope the insurance wouldn't

think this was done for a purely cosmetic reason. We'll see what

comes about!

Thanks again!

& Kaylie

> >

> > Hi all,

> > 1st off thanks for all of your comments on the helmet cost

> > question I asked yesterday, you're all so helpful. Although I

am

> > not sure if Kaylie will need the helmet yet, I went ahead &

> checked

> > with our insurance & they said it would be covered if it

were " of

> > medical necessity " . They said our physician will need to send

> > records & any recommendation to their medical review dept.

> >

> > Does this sound familiar to anyone?

> >

> > And what is the wording from Kaylie's physician that needs to be

> > stated to proclaim medical necessity?

> >

> > We believe she has torticollis from birth, maybe a bit of plagio

&

> > now her face is asymmetrical.

> >

> > Thanks!

> >

> > & Kaylie

> >

>