Re: ] definity/united healthcare preauthorization appeal denial- help!

[Guest guest]

Hi Ally,

I too was denied with UHC. We ended up paying for the band out of pocket. We are now trying to get reimbursed for our DOC band. My policy states that DME is covered, however in my policy it has a exclusion in regards to the helmet. (Braces that straighten or change the shape of a body part are orthotic devices and are excluded from coverage.) This is the hurdle that I am trying to get around. Does your policy have any type of exclusion? I know there have been people that have been approved with UHC. I spoke with a lady on another site, her policy stated "includes orthotic devices which are required for support for an injured or deformed part of the body as a result of a disabling congenital condition, an illness or an injury." I guess this is another way to get UHC to approve your band, if your policy is similar to this one.

Best of Luck

Lorie

Mom to Spencer and Ali 18 months

Spencer- Left Plagio- DOC Band GRAD

Arizona

Best of luck

[sPAM] definity/united healthcare preauthorization appeal denial- help!

Has anyone successfully appealed to United and gotten coverage for ahelmet? I used the letters posted on this site to help me write theappeal and it still was denied. I don't get it. The helmet is clearly durable medical equipment (DME)and according to the policy DME is covered! I feel so helpless. My little guy is 6 months old and I know thelonger we wait to get a helmet the longer he'll have to wear it.I'd love to hear words of encouragement! thanks for reading my venting!!Ally in Rhode Island

[Guest guest]

Ally & Lorie ( & anyone else dealing with insurance!)

I too was just denied coverage for my son's STARband from UHC. I

guess they are notoriously bad about paying for the cranial bands -

my orthotist told me this from the start.

Our reason for denial was also because of the exclusion of " orthotic

devices that straighten or reposition a body part are excluded " .

I am still waiting to see an actual paper copy of my coverage details

to see if there is some language somewhere else in the policy that

can help me out.

I also found some info about writing appeal letters at the

Cappskids.org website - it's worth checking out if you haven't

already.

We did go ahead and band my son not knowing if UHC would approve it,

and we are prepared to pay for it if we have to, but hopefully our

appeal will be successful.

Please let me know what your next steps are - hopefully we can help

out each other!

Jenn - Chicago

- 7 months, plagio & tort - STARband 3 weeks

>

> Hi Ally,

> I too was denied with UHC. We ended up paying for the band out of

pocket. We are now trying to get reimbursed for our DOC band. My

policy states that DME is covered, however in my policy it has a

exclusion in regards to the helmet. (Braces that straighten or change

the shape of a body part are orthotic devices and are excluded from

coverage.) This is the hurdle that I am trying to get around. Does

your policy have any type of exclusion? I know there have been people

that have been approved with UHC. I spoke with a lady on another

site, her policy stated " includes orthotic devices which are required

for support for an injured or deformed part of the body as a result

of a disabling congenital condition, an illness or an injury. " I

guess this is another way to get UHC to approve your band, if your

policy is similar to this one.

>

> Best of Luck

>

> Lorie

> Mom to Spencer and Ali 18 months

> Spencer- Left Plagio- DOC Band GRAD

> Arizona

>

> Best of luck

> [sPAM] definity/united healthcare

preauthorization appeal denial- help!

>

>

> Has anyone successfully appealed to United and gotten coverage

for a

> helmet? I used the letters posted on this site to help me write

the

> appeal and it still was denied.

>

> I don't get it. The helmet is clearly durable medical equipment

(DME)

> and according to the policy DME is covered!

>

> I feel so helpless. My little guy is 6 months old and I know the

> longer we wait to get a helmet the longer he'll have to wear it.

>

> I'd love to hear words of encouragement! thanks for reading my

venting!!

>

> Ally in Rhode Island

>

[Guest guest]

> >

> > Hi Ally,

> > I too was denied with UHC. We ended up paying for the band out

of

> pocket. We are now trying to get reimbursed for our DOC band. My

> policy states that DME is covered, however in my policy it has a

> exclusion in regards to the helmet. (Braces that straighten or

change

> the shape of a body part are orthotic devices and are excluded from

> coverage.) This is the hurdle that I am trying to get around. Does

> your policy have any type of exclusion? I know there have been

people

> that have been approved with UHC. I spoke with a lady on another

> site, her policy stated " includes orthotic devices which are

required

> for support for an injured or deformed part of the body as a result

> of a disabling congenital condition, an illness or an injury. " I

> guess this is another way to get UHC to approve your band, if your

> policy is similar to this one.

> >

> > Best of Luck

> >

> > Lorie

> > Mom to Spencer and Ali 18 months

> > Spencer- Left Plagio- DOC Band GRAD

> > Arizona

> >

> > Best of luck

> > [sPAM] definity/united healthcare

> preauthorization appeal denial- help!

> >

> >

> > Has anyone successfully appealed to United and gotten coverage

> for a

> > helmet? I used the letters posted on this site to help me write

> the

> > appeal and it still was denied.

> >

> > I don't get it. The helmet is clearly durable medical equipment

> (DME)

> > and according to the policy DME is covered!

> >

> > I feel so helpless. My little guy is 6 months old and I know the

> > longer we wait to get a helmet the longer he'll have to wear it.

> >

> > I'd love to hear words of encouragement! thanks for reading my

> venting!!

> >

> > Ally in Rhode Island

> >

>

Ally,

I wouldn't waste anymore time trying to get coverage before the

banding. It takes far too long to get through all the red tape at

UHC. They messed up on the processing our claim so many times it was

unreal. Get the band first, and fight later. They will probably

still deny coverage in the long run, but at least you can get your

son treated.

Jeff in Ohio

[Guest guest]

Ally and Lori,

My wife and I recently made the decision to bite the bullet and pay

for a Star band for our son (7 months old, 2nd week in the band, all

is well so far!), knowing UHC would most likely cover the therapy

sessions but deny the actual equipment. We just found out last week

that they approved the therapy sessions, but we have not yet

submitted our claim for the helmet (I'm putting the finishing touches

on the cover letter).

After reading through our policy (which, since we live in Florida,

may contain slightly different language than yours), I noticed, like

yours, it also covers DME (check the definition for DME under your

policy to make sure cranial bands meet every factor) but specifically

excludes cranial bands. My argument to UHC is that this is an

arbitrary and capricious exclusion that is contrary to official

policy of the American Medical Association (I know you've read those

arguments in other sample letters). Specifically, I am focusing on

the fact that the policy covers braces which are used to repair

injured body parts, but not those used to reshape otherwise uninjured

body parts.

In our son's case, his plagio can be attributed to the fact that he

had colic for the first few months of his life and, accordingly, he

spent hours at a time in his swing on a daily basis. That's the

injury. The time spent in the swing, which we were advised to do in

order to help soothe his colic, is what led to the plagio. As a

result, the cranial band in this particular scenario is, indeed,

functioning more like leg braces, which are specifically listed as

covered DME under our policy. Because our son's case is a perfect

example of the use of cranial bands to treat an injured body part,

the general exclusion of cranial bands, without at the very least a

case-by-case analysis, is arbitrary and capricious.

Whether this will convince UHC to approve our claim remains to be

seen. However, my goal is not only to convince them to cover the

band but also to illustrate to them that they must revisit this issue

internally and come to the realization that they must revise their

policies and remove the general exclusion of cranial bands because

(a) the instances of positional plagio are going to continue to rise

due to the fear of the alternative (i.e., risk of SIDS), ( if left

untreated plagio can cause additional issues in the future (e.g.,

sinus, vision and hearing problems, TMJ, etc.), and © it is cheaper

to cover the relatively low cost of the cranial band now than it most

likely will be to cover the cost of treatment for the aforementioned

issues in the future.

When they deny coverage, in my appeal I am going to revisit the

arbitrary and capricious theme and point out the inherent ambiguity

in covering the therapy sessions but not the equipment used by the

therapist. After all, it is certainly reasonable to assume that if

UHC will pay for us to see a therapist that they would trust the

therapist's opinion that our son needs to be in a cranial band.

That's just plain common sense.

Like I said, I don't know if it's going to work, but it's definitely

worth the effort. I'll keep you posted as to how it all turns out.

Take care,

Steve

Daddy to , 7 months old, 2 weeks in Star band

>

> Hi Ally,

> I too was denied with UHC. We ended up paying for the band out of

pocket. We are now trying to get reimbursed for our DOC band. My

policy states that DME is covered, however in my policy it has a

exclusion in regards to the helmet. (Braces that straighten or change

the shape of a body part are orthotic devices and are excluded from

coverage.) This is the hurdle that I am trying to get around. Does

your policy have any type of exclusion? I know there have been people

that have been approved with UHC. I spoke with a lady on another

site, her policy stated " includes orthotic devices which are required

for support for an injured or deformed part of the body as a result

of a disabling congenital condition, an illness or an injury. " I

guess this is another way to get UHC to approve your band, if your

policy is similar to this one.

>

> Best of Luck

>

> Lorie

> Mom to Spencer and Ali 18 months

> Spencer- Left Plagio- DOC Band GRAD

> Arizona

>

> Best of luck

> [sPAM] definity/united healthcare

preauthorization appeal denial- help!

>

>

> Has anyone successfully appealed to United and gotten coverage

for a

> helmet? I used the letters posted on this site to help me write

the

> appeal and it still was denied.

>

> I don't get it. The helmet is clearly durable medical equipment

(DME)

> and according to the policy DME is covered!

>

> I feel so helpless. My little guy is 6 months old and I know the

> longer we wait to get a helmet the longer he'll have to wear it.

>

> I'd love to hear words of encouragement! thanks for reading my

venting!!

>

> Ally in Rhode Island

>

[Guest guest]

Steve

The cranial bands do meet the definition for DME- in our first letter

I went point by point in the definition in the summary plan

description. (I really think they didn't read my letter)

But what really burns me is that UHC actually considers it a

reconstructive therapy (which therefore should be covered) but chooses

to inappropriately apply language from the medical supplies section to

deny the claim. (as if it's in the same category as ace bandages or

elevated toilet seats!)

If you go to

http://www.welcometounitedhealthcareonline.com/demo/b2c/networkbulletin.html

and read page 9 of the March 2008 newsletter you will see the policy

update on treating plagiocephaly. Our son far exceeds the measurement

requirements (which the orthotics people felt was too strict- other

insurers only require a difference of 6mm) . In the first appeal

letter I quoted the newsletter but in the second one I am attaching

the actual newsletter and I'm going to circle the wording in black marker.

It was the customer service rep (who actually told me it was approved

and then looked closer and said that it was denied- don't get me

started on the appalling poor customer service. I've been told twice

in error that the helmet was approved) who recommended that I attach

the actual newsletter. They did tell me that if I purchased the

helmet BEFORE precertification that they would not cover it even if it

was approved.

The orthotics folks said that they have seen it covered by UHC in the

past and there didn't seem to be any rhyme or reason as to why one

claim was approved and one wasn't. They also said that they've

submitted claims that did not have precertification approval and they

have been paid! They did say that persistence has paid off for some

people.

When this is over I'm going to write a letter to my employer about the

treatment I've received from their customer service department.

So.. we went and got another scan yesterday and ordered the helmet. I

just won't pick it up until I hear yes or no from UHC. We'll get it

either way.

Good luck and I'll keep everyone posted. I'll upload my letters if we

actually get approval.

-Ally

-- In Plagiocephaly , " stevenmharper "

<stevenmharper@...> wrote:

>

> Ally and Lori,

>

> My wife and I recently made the decision to bite the bullet and pay

> for a Star band for our son (7 months old, 2nd week in the band, all

> is well so far!), knowing UHC would most likely cover the therapy

> sessions but deny the actual equipment. We just found out last week

> that they approved the therapy sessions, but we have not yet

> submitted our claim for the helmet (I'm putting the finishing touches

> on the cover letter).

>

> After reading through our policy (which, since we live in Florida,

> may contain slightly different language than yours), I noticed, like

> yours, it also covers DME (check the definition for DME under your

> policy to make sure cranial bands meet every factor) but specifically

> excludes cranial bands. My argument to UHC is that this is an

> arbitrary and capricious exclusion that is contrary to official

> policy of the American Medical Association (I know you've read those

> arguments in other sample letters). Specifically, I am focusing on

> the fact that the policy covers braces which are used to repair

> injured body parts, but not those used to reshape otherwise uninjured

> body parts.

>

> In our son's case, his plagio can be attributed to the fact that he

> had colic for the first few months of his life and, accordingly, he

> spent hours at a time in his swing on a daily basis. That's the

> injury. The time spent in the swing, which we were advised to do in

> order to help soothe his colic, is what led to the plagio. As a

> result, the cranial band in this particular scenario is, indeed,

> functioning more like leg braces, which are specifically listed as

> covered DME under our policy. Because our son's case is a perfect

> example of the use of cranial bands to treat an injured body part,

> the general exclusion of cranial bands, without at the very least a

> case-by-case analysis, is arbitrary and capricious.

>

> Whether this will convince UHC to approve our claim remains to be

> seen. However, my goal is not only to convince them to cover the

> band but also to illustrate to them that they must revisit this issue

> internally and come to the realization that they must revise their

> policies and remove the general exclusion of cranial bands because

> (a) the instances of positional plagio are going to continue to rise

> due to the fear of the alternative (i.e., risk of SIDS), ( if left

> untreated plagio can cause additional issues in the future (e.g.,

> sinus, vision and hearing problems, TMJ, etc.), and © it is cheaper

> to cover the relatively low cost of the cranial band now than it most

> likely will be to cover the cost of treatment for the aforementioned

> issues in the future.

>

> When they deny coverage, in my appeal I am going to revisit the

> arbitrary and capricious theme and point out the inherent ambiguity

> in covering the therapy sessions but not the equipment used by the

> therapist. After all, it is certainly reasonable to assume that if

> UHC will pay for us to see a therapist that they would trust the

> therapist's opinion that our son needs to be in a cranial band.

> That's just plain common sense.

>

> Like I said, I don't know if it's going to work, but it's definitely

> worth the effort. I'll keep you posted as to how it all turns out.

>

> Take care,

>

> Steve

> Daddy to , 7 months old, 2 weeks in Star band

>

>

> >

> > Hi Ally,

> > I too was denied with UHC. We ended up paying for the band out of

> pocket. We are now trying to get reimbursed for our DOC band. My

> policy states that DME is covered, however in my policy it has a

> exclusion in regards to the helmet. (Braces that straighten or change

> the shape of a body part are orthotic devices and are excluded from

> coverage.) This is the hurdle that I am trying to get around. Does

> your policy have any type of exclusion? I know there have been people

> that have been approved with UHC. I spoke with a lady on another

> site, her policy stated " includes orthotic devices which are required

> for support for an injured or deformed part of the body as a result

> of a disabling congenital condition, an illness or an injury. " I

> guess this is another way to get UHC to approve your band, if your

> policy is similar to this one.

> >

> > Best of Luck

> >

> > Lorie

> > Mom to Spencer and Ali 18 months

> > Spencer- Left Plagio- DOC Band GRAD

> > Arizona

> >

> > Best of luck

> > [sPAM] definity/united healthcare

> preauthorization appeal denial- help!

> >

> >

> > Has anyone successfully appealed to United and gotten coverage

> for a

> > helmet? I used the letters posted on this site to help me write

> the

> > appeal and it still was denied.

> >

> > I don't get it. The helmet is clearly durable medical equipment

> (DME)

> > and according to the policy DME is covered!

> >

> > I feel so helpless. My little guy is 6 months old and I know the

> > longer we wait to get a helmet the longer he'll have to wear it.

> >

> > I'd love to hear words of encouragement! thanks for reading my

> venting!!

> >

> > Ally in Rhode Island

> >

>

[Guest guest]

Hi Steve,

UHC seems to deny everyone, and pay some on appeal. I don't have UHC,

but it is something I've noticed here in the past 2+ years. I'm not

sure they can even justify their own position. I think it is just a

way to save $, since many people won't bother to appeal multiple

times. I'm just guessing so I hope they don't sue me for slander ;-)

Let us know what happens with your appeal. Also let us know how

does in his band.

-christine

sydney 2.5 yrs starband grad

> >

> > Hi Ally,

> > I too was denied with UHC. We ended up paying for the band out of

> pocket. We are now trying to get reimbursed for our DOC band. My

> policy states that DME is covered, however in my policy it has a

> exclusion in regards to the helmet. (Braces that straighten or change

> the shape of a body part are orthotic devices and are excluded from

> coverage.) This is the hurdle that I am trying to get around. Does

> your policy have any type of exclusion? I know there have been people

> that have been approved with UHC. I spoke with a lady on another

> site, her policy stated " includes orthotic devices which are required

> for support for an injured or deformed part of the body as a result

> of a disabling congenital condition, an illness or an injury. " I

> guess this is another way to get UHC to approve your band, if your

> policy is similar to this one.

> >

> > Best of Luck

> >

> > Lorie

> > Mom to Spencer and Ali 18 months

> > Spencer- Left Plagio- DOC Band GRAD

> > Arizona

> >

> > Best of luck

> > [sPAM] definity/united healthcare

> preauthorization appeal denial- help!

> >

> >

> > Has anyone successfully appealed to United and gotten coverage

> for a

> > helmet? I used the letters posted on this site to help me write

> the

> > appeal and it still was denied.

> >

> > I don't get it. The helmet is clearly durable medical equipment

> (DME)

> > and according to the policy DME is covered!

> >

> > I feel so helpless. My little guy is 6 months old and I know the

> > longer we wait to get a helmet the longer he'll have to wear it.

> >

> > I'd love to hear words of encouragement! thanks for reading my

> venting!!

> >

> > Ally in Rhode Island

> >

>

[Guest guest]

Steve, Ally & Lori

It seems like we are all in the same boat with UHC. We were denied

because " orthotic appliances that straighten or reshape a body part

are not covered a benefit " . However, my husband and I can't find

this wording in our coverage documents - neither can the HR

department at his company. So HR is supposed to be contacting UHC to

find out where the language for this exclusion is - I'll keep you

posted.

I did look at the newsletter from UHC online that someone mentioned -

and it seems to me that UHC will cover the helmet if the plagio is

severe - am I not understanding it correctly?

SO frustrating!!

Hopefully we can help each other out...

Jenn

- 7 months - plagio & tort- 3 weeks STARband

> > >

> > > Hi Ally,

> > > I too was denied with UHC. We ended up paying for the band

out of

> > pocket. We are now trying to get reimbursed for our DOC band. My

> > policy states that DME is covered, however in my policy it has a

> > exclusion in regards to the helmet. (Braces that straighten or

change

> > the shape of a body part are orthotic devices and are excluded

from

> > coverage.) This is the hurdle that I am trying to get around.

Does

> > your policy have any type of exclusion? I know there have been

people

> > that have been approved with UHC. I spoke with a lady on another

> > site, her policy stated " includes orthotic devices which are

required

> > for support for an injured or deformed part of the body as a

result

> > of a disabling congenital condition, an illness or an injury. " I

> > guess this is another way to get UHC to approve your band, if

your

> > policy is similar to this one.

> > >

> > > Best of Luck

> > >

> > > Lorie

> > > Mom to Spencer and Ali 18 months

> > > Spencer- Left Plagio- DOC Band GRAD

> > > Arizona

> > >

> > > Best of luck

> > > [sPAM] definity/united healthcare

> > preauthorization appeal denial- help!

> > >

> > >

> > > Has anyone successfully appealed to United and gotten

coverage

> > for a

> > > helmet? I used the letters posted on this site to help me

write

> > the

> > > appeal and it still was denied.

> > >

> > > I don't get it. The helmet is clearly durable medical

equipment

> > (DME)

> > > and according to the policy DME is covered!

> > >

> > > I feel so helpless. My little guy is 6 months old and I know

the

> > > longer we wait to get a helmet the longer he'll have to wear

it.

> > >

> > > I'd love to hear words of encouragement! thanks for reading

my

> > venting!!

> > >

> > > Ally in Rhode Island

> > >

> >

>