CIGNA New Mexico Denied Coverage - Anyone else in NM get paid?

[Guest guest]

Hi y'all, I haven't done much posting here because I can usually get

my questions answered just by browsing. But here's a specific one

that I need help with. My daughter got her Hanger helmet in March,

and we were in such a hurry to get her started (at 10 months old) that

I didn't want to slow down the process with insurance approvals.

Well, now of course we're paying the price, literally. I've been

through the appeals process, but CIGNA's plan states that it excludes

coverage for cranial orthoses except post-surgically, which hers is

not. Note that it's not excluded based on medical necessity (which I

could easily prove) but just is flat out not covered. Sounds like

there's no hope for getting them to change their minds. But I have

one last appeal left, and I think the only thing that might work is if

I could show that they had made an exception for someone else on this

plan in NM. So my question is, have any of you had CIGNA in NM pay

for your helmet/band although it was specifically excluded from

coverage, not just based on medical necessity?

Thanks for any help!

[Guest guest]

Hello,

I am not in NM but we received the same reason for denial and I also

appealed it and they denied it again. Good luck. I never got my

daughters covered by CIGNA.

Mom to Abby 10 months DOC band gradaute as of tom.

>

> Hi y'all, I haven't done much posting here because I can usually get

> my questions answered just by browsing. But here's a specific one

> that I need help with. My daughter got her Hanger helmet in March,

> and we were in such a hurry to get her started (at 10 months old)

that

> I didn't want to slow down the process with insurance approvals.

> Well, now of course we're paying the price, literally. I've been

> through the appeals process, but CIGNA's plan states that it

excludes

> coverage for cranial orthoses except post-surgically, which hers is

> not. Note that it's not excluded based on medical necessity (which

I

> could easily prove) but just is flat out not covered. Sounds like

> there's no hope for getting them to change their minds. But I have

> one last appeal left, and I think the only thing that might work is

if

> I could show that they had made an exception for someone else on

this

> plan in NM. So my question is, have any of you had CIGNA in NM pay

> for your helmet/band although it was specifically excluded from

> coverage, not just based on medical necessity?

>

> Thanks for any help!

>

[Guest guest]

I found CIGNA's coverage position on Cranial Orthotics, and according

to their coverage position, surgery isn't a pre-req if other

conditions are met. It won't let me cut and paste from that

document, but it states (briefly) that if there is photographic

evidence of moderate to severe nonsynostotic plagiocephaly AND either

the child is between 3-5 months and has not responded to a two month

trial of repositioning OR the child is between 6-18 months. They

also have a criteria for what determines moderate to severe -

Cephalic index + or - at least 2 SD or asymmetry of 12mm or more in

certain measures. There are charts attached to the position that

make this a little more clear.

The link to the coverage position is

http://www.cigna.com/customer_care/healthcare_professional/coverage_po

sitions/medical/mm_0056_coveragepositioncriteria_cranial_orthotic_devi

ces.pdf

This is not specific to New Mexico, and New Mexico could, I suppose

have a different one, but I would recommend appealing based on the

information in CIGNA's own documentation that surgery ISN'T a

required pre-req.

Good Luck

M

>

> Hi y'all, I haven't done much posting here because I can usually get

> my questions answered just by browsing. But here's a specific one

> that I need help with. My daughter got her Hanger helmet in March,

> and we were in such a hurry to get her started (at 10 months old)

that

> I didn't want to slow down the process with insurance approvals.

> Well, now of course we're paying the price, literally. I've been

> through the appeals process, but CIGNA's plan states that it

excludes

> coverage for cranial orthoses except post-surgically, which hers is

> not. Note that it's not excluded based on medical necessity (which

I

> could easily prove) but just is flat out not covered. Sounds like

> there's no hope for getting them to change their minds. But I have

> one last appeal left, and I think the only thing that might work is

if

> I could show that they had made an exception for someone else on

this

> plan in NM. So my question is, have any of you had CIGNA in NM pay

> for your helmet/band although it was specifically excluded from

> coverage, not just based on medical necessity?

>

> Thanks for any help!

>

[Guest guest]

I wanted to add that we got CIGNA to cover us in 2000 after being given three reasons for denial (in one letter) - including not needing surgery. In our case, our son looked exactly like he had his sattigal suture fused -- it wasn't. We used photographic evidence of "repositioning" as well as medical infomation regarding his birth and head shape (he was breech, and head shape happened inutero), and we did get a letter of medical necessity from the pediatric neurosurgeon (who was not pro-band at all, but at least mentioned that DS could not lay flat on his back because of the size of the back of his head). I took each "point" that they denied us, and gave information/evidence of the contrary. In the case of not needing surgery I stressed that the reason why he got his head x-rayed and CT scanned was to rule out sattigal craniosynostosis, so if he looked exactly like a child with cranio why would they deny him molding therapy without the surgery if they would have given him the molding therapy after surgery? I stated it a little clearer than that, but I'm sure you get my meaning. In any case, I would appeal -- (find out how many appeals that you are allowed). We used several pages of pictures -- some just with the head shape, others showing repositioning, and a comparison of a child with sattigal cranio and DS's headshape. Yeah, a little overkill, but they paid for the band on first appeal... (in Ohio)Mom to Quinn, born 11/99, DOCband grad 10/00.>------- Original Message ------->From : missmailelynn[mailto:missmailelynn@...]>Sent : 7/30/2008 9:56:19 AM>To : Plagiocephaly >Cc : >Subject : RE: Re: CIGNA New Mexico Denied Coverage - Anyone else in NM get paid?>>I found CI

GNA's coverage position on Cranial Orthotics, and according to their coverage position, surgery isn't a pre-req if other conditions are met. It won't let me cut and paste from that document, but it states (briefly) that if there is photographic evidence of moderate to severe nonsynostotic plagiocephaly AND either the child is between 3-5 months and has not responded to a two month trial of repositioning OR the child is between 6-18 months. They also have a criteria for what determines moderate to severe - Cephalic index + or - at least 2 SD or asymmetry of 12mm or more in certain measures. There are charts attached to the position that make this a little more clear.The link to the coverage position is http://www.cigna.com/customer_care/healthcare_professional/coverage_po sitions/medical/mm_0056_coveragepositioncriteria_crani

al_orthotic_devices.pdfThis is not specific to New Mexico, and New Mexico could, I suppose have a different one, but I would recommend appealing based on the information in CIGNA's own documentation that surgery ISN'T a required pre-req.Good Luck :)M>> Hi y'all, I haven't done much posting here because I can usually get> my questions answered just by browsing. But here's a specific one> that I need help with. My daughter got her Hanger helmet in March,> and we were in such a hurry to get her started (at 10 months old) that> I didn't want to slow down the process with insurance approvals. > Well, now of course we're paying the price, literally. I've been> through the appeals process, but CIGNA's plan states that it excludes> coverage for cranial orthoses except post-surgically, whic

h hers is> not. Note that it's not excluded based on medical necessity (which I> could easily prove) but just is flat out not covered. Sounds like> there's no hope for getting them to change their minds. But I have> one last appeal left, and I think the only thing that might work is if> I could show that they had made an exception for someone else on this> plan in NM. So my question is, have any of you had CIGNA in NM pay> for your helmet/band although it was specifically excluded from> coverage, not just based on medical necessity?> > Thanks for any help!>------------------------------------For more plagio info