Was told by Cigna there was an exclusion, found out later it is covered

[Guest guest]

sorry this is a fairly long post but I'm hoping it may help someone

in the future. I will number the information in the order that I

found it out:

1.Cranial Tech called to tell me that they called Cigna and they don't

cover the DOC band because of an exclusion in the policy. I think

that I need to contact Cigna myself to see what that exclusion is,

like whether it is considered " not medically neccesary " I need the

specific wording. I read something on Cigna's website called

a " Coverage Position " that specifically talks about coverage for

cranial orhtotic devices, but it does say that some Cigna plans may

specifically exclude or limit coverage.

2.I called Cigna yesterday and spoke to a Rep. that was nice. I

asked her if my plan covers a cranial orthotic device. she asked

what that was and I explained it. At first she couldn't find

anything then I asked her to look under durable medical equipment and

still nothing, then I asked her to look under External Prosthetic

Apliance and Devices and she found the exclusion there! I asked her

if she could fax me what she saw and she said she could have a letter

written up for me explaining that and it would be faxed that

afternoon or the next day. I just received the fax. I can't scan it

here at work but I can type what it says:

On March 25, 2008 you called to inquire on your plan benefits. This

benefit was for External Prosthetic Appliance [EPA]. After reviewing

your benefits it has been determined that the EAP you were inquiring

on is listed in your exclusion of benefits.

EAP exclusions under your plan are as follows

Excludes the following orhoses & orthotic devices: prefabricated foot

orthoses; cranial banding/cranial orthoses/other similar devices

except when used postoperatively for synostic plagiocephaly; and

moderate to severe nonsynostotic positional plagiocepahly as

medically necessary: ext.

3.After reading the exclusion again I read it as saying:

excludes cranial banding except when used for moderate to severe

nonsynostoic positional plagiocephaly as medically necessary. This

to me means that if the doctor sends the note of medical neccessity

and meets the conditions then there is coverage.

I read the " coverage position " (found on Cigna's website) as saying:

Coverage for cranial orthotic devices is generally subject to the

terms, conditions and limitations of the External Prosthetic

Appliance and Devices benefit.

If coverage for a cranial orthotic device is available, the following

conditions of coverage apply.

Cigna covers a cranial orhtotic device as medicall necessary for the

treatment of either of the following conditions:

& #56256; & #56510; synostotic plagiocephaly following surgical correction

& #56256; & #56510; moderate to severe nonsynostotic positional plagiocephaly when

ALL

of the following conditions are met:

& #56256; & #56510; There is photographic evidence supporting moderate to severe

nonsynostotic positional

plagiocephaly.

& #56256; & #56510; The child is EITHER ONE of the following:

o between three and five months of age and has failed to respond to a

two-month

trial of repositioning therapy

o age six months to 18 months of age

& #56256; & #56510; There is documentation of EITHER of the following criteria:

o cephalic index ± at least two standard deviations from the mean for

the

appropriate gender/age (see Table 1)

o asymmetry of 12 mm or more in ONE of the following measures:

& #56256; & #56451; cranial vault

& #56256; & #56451; skull base

& #56256; & #56451; orbitotragial depth (see Table 2)

meets this criteria.

I just got back from meeting with a nurse in our company (we have

nurse advocates here) and she said this means we are covered and that

cranial tech should be sending the doctor's letter and prescription

to Cigna and it should be covered. She is going to take my info and

contact her Cigna rep to get them talking to cranial tech and she

also said " Good Job " .