Re: Insurance denial-new to group

[Guest guest]

Hi Nikki -

We have TRICARE as our insurance and they have a specific exclusion for non-synostotic orthotic devices. Basically, you can crack your child's skull, THEN they'll pay for the helmet, which I think is criminal and completely illogical. Anyway, we are in the process of the appeal to be reimbursed for the helmet.

The items you definitely want to include are the diagnoses from all the specialists. If you can get letters stating the need for the helmet that cite specifically it is NOT for cosmetic purposes, that helps as well. We have letters from Liam's neurosurgeon, the craniofacial board at the hospital as well as the orthotist. His bracycephaly is such that not getting a helmet would result in definite surgery, which is what we want to avoid at all costs. You also probably want to include the following AMA documentation that states that the helmet is NOT utilized primarily for cosmetic purposes: AMA H-185.967, AMA H-475.992 and AMA Resolution 119. There are also two legal cases dealing with this issue that we cited: Bynum v. Cigna Healthcare and v. State of South Carolina.

I have all this documentation if you (or anyone in the group) would like to e-mail me.

Good Luck!

Mom to Liam, 8 months

Diagnosed with deformational positional plagiocephaly (3NOV08) & bracycephaly (17FEB09), started STARBand 25Feb09

From: fredandnikki <fredandnikki@...>Plagiocephaly Sent: Wednesday, February 25, 2009 4:55:44 PMSubject: Insurance denial-new to group

HI!I'm new to this group. Both of our insurances have denied coverage of the DOC-Band. Our secondary, United denied as an exclusion and our primary denied as not medically necessary. We're going to appeal with our primary, but curious if anyone has experience with writing appeals and what information you included. Basically, they told me that they wouldn't cover the band until we had completed 63 WEEKS of repositional therapy!! Any help would be great!Nikki-mom to