Guest guest Posted June 29, 2005 Report Share Posted June 29, 2005 Hi- I am new to the group. I wondered if anyone had experience getting an HMO to pay for needed expert care out of state. In brief, our story is that our son, Theo, was born in August of 2004. We found out he had a severe right clubfoot in the delivery room, which now seems strange, given that I myself am a physician at an academic medical center and I had 4 ultrasounds while pregnant and it was never discovered. Theo also had apneas at birth and was in the ICU for 2 weeks. The apneas resolved and we were " left " with the clubfoot. Even though the pediatrician in the delivery room had pronounced the news of the clubfoot to us in the most somber tones, I looked at it as correctable and felt positive about the treatment. Unfortunately, my optimism and the early course with more concern about the apneas led us to assume Theo would get good care at our center. When the MD told us he had " trained with Ponseti " we took this at face value. After 6-7 casts and a posterior tenotomy, the MD put Theo in a non-standard AFO " because he has so much equinus " . My gut (as in your message!) told me something was very wrong, but we kept going. Long story short, of course Theo's foot relapsed and the MD now told us we should see a neurologist because Theo couldn't dorsiflex and " doesn't have the garden variety clubfoot " (whatever garden variety clubfoot is). Right then, I told myself that we were never going back to that doctor. I contacted Dr Ponseti himself who told me that no MDs in Michigan were qualified, that many say they " trained " with him but to get qualified is another matter. He highly recommended Dr Herzenberg in Baltimore who has been wonderful. Dr Herzenberg told us by looking at the AFO that Theo had been given as well as the casts we had saved that the treatment Theo had received had significantly deviated from Ponseti's protocol. He estimated that the MD had only gotten Theo to 30 degrees of lateral correction as opposed to the 70 degree standard. He noted that Theo couldn't dorsiflex due to the fact that the ankle bones were as yet uncorrected. As it stands now, we fly back and forth to Baltimore each week but after 4 casts, Theo is at nearly 70 degrees of lateral correction. He will need another tenotomy but we feel we are in excellent hands with Dr Herzenberg. We currently have appealed our insurance companies' rejection of treatment in Baltimore (they said " care could be provided at Michigan " ) by furnishing them with 17 pages of the history above with references, pictures (Theo's AFO vs. Denis-Browne brace) and articles by Ponseti and Herzenberg). Just wondered anyone else had success with appealing to an HMO and thoughts on the best approach. thanks! Helen Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 29, 2005 Report Share Posted June 29, 2005 Hi- I am new to the group. I wondered if anyone had experience getting an HMO to pay for needed expert care out of state. In brief, our story is that our son, Theo, was born in August of 2004. We found out he had a severe right clubfoot in the delivery room, which now seems strange, given that I myself am a physician at an academic medical center and I had 4 ultrasounds while pregnant and it was never discovered. Theo also had apneas at birth and was in the ICU for 2 weeks. The apneas resolved and we were " left " with the clubfoot. Even though the pediatrician in the delivery room had pronounced the news of the clubfoot to us in the most somber tones, I looked at it as correctable and felt positive about the treatment. Unfortunately, my optimism and the early course with more concern about the apneas led us to assume Theo would get good care at our center. When the MD told us he had " trained with Ponseti " we took this at face value. After 6-7 casts and a posterior tenotomy, the MD put Theo in a non-standard AFO " because he has so much equinus " . My gut (as in your message!) told me something was very wrong, but we kept going. Long story short, of course Theo's foot relapsed and the MD now told us we should see a neurologist because Theo couldn't dorsiflex and " doesn't have the garden variety clubfoot " (whatever garden variety clubfoot is). Right then, I told myself that we were never going back to that doctor. I contacted Dr Ponseti himself who told me that no MDs in Michigan were qualified, that many say they " trained " with him but to get qualified is another matter. He highly recommended Dr Herzenberg in Baltimore who has been wonderful. Dr Herzenberg told us by looking at the AFO that Theo had been given as well as the casts we had saved that the treatment Theo had received had significantly deviated from Ponseti's protocol. He estimated that the MD had only gotten Theo to 30 degrees of lateral correction as opposed to the 70 degree standard. He noted that Theo couldn't dorsiflex due to the fact that the ankle bones were as yet uncorrected. As it stands now, we fly back and forth to Baltimore each week but after 4 casts, Theo is at nearly 70 degrees of lateral correction. He will need another tenotomy but we feel we are in excellent hands with Dr Herzenberg. We currently have appealed our insurance companies' rejection of treatment in Baltimore (they said " care could be provided at Michigan " ) by furnishing them with 17 pages of the history above with references, pictures (Theo's AFO vs. Denis-Browne brace) and articles by Ponseti and Herzenberg). Just wondered anyone else had success with appealing to an HMO and thoughts on the best approach. thanks! Helen Quote Link to comment Share on other sites More sharing options...
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