Re: Insurance Company Denied Cranial Molding Helmet

[Guest guest]

I am in the same boat you are...I have Cigna and they are claiming our plan doesn't cover the band at all. However when we first went to Cranial Tech for our consultation when my son was 3 months old, the employee in charge of insurance claims for CT contacted Cigna and they told her my plan did in fact cover the band if he was more than 12mm assymetrical and we had been repositioning for 8 weeks. She specifically asked about exclusions and our copay which they said would be $500. Well at the time we had only been repositioning for 6 weeks and that was in the report. So we waited 2 weeks and went back for more measurements. They found a difference of 16mm and we had been repositioning for 8 weeks, therefore we should be covered right?!?! The same employee of CT called to make sure the information remained the same, they restated the requirements and copay. We made an appt for his imaging and we were under the assumption he would be getting the band. At that point Cranial Tech submitted the paperwork to Cigna and a couple days before the imaging appt Cranial Tech called me and said we had been denied. I called Cigna and the reason we were denied was because apparently my plan doesn't cover cranial bands at all, unless it is post surgery. I too thought that was ridiculous, they would rather put an infant through surgery and pay for that rather than pay for the helmet. I looked up Cigna's plan online and saw that they do cover bands with the requirements we were given on the phone. I called Cigna back and got the same information that they do not cover them in our plan, I asked if I could see that in writing and then I got the run-around being transferred from dept to dept until finally someone said that it was only on their computer screen and that I can not receive it in writing. As of right now we paid for the DocBand out of pocket however CT did give us "Cigna's contracted rate" of $2500. He has been in the band just less than 2 weeks. I plan on writing the letter of appeal this week. Is it worth my time? What should I write? I am completely clueless when it comes to insurance companies so any information would be greatly appreciated.

By the way, the other person whom Cigna denied...do you happen to be an employee of Miami Dade County Public Schools? Everyone else I know who has Cigna doesn't have as many problems as my plan with my employer does. So far it cost me $3000 for my son's birth! I say so far because 4 months later I am still receiving medical bills. When I had United for my older son, his birth was $250. Plus with Cigna I have had to appeal several of my prenatal ultrasounds that they first denied.

A big thank you to everyone in this group! I feel so much more knowledgeable on helmets and plagiocephaly after reading all your messages.

Thanks,

Tara

[Guest guest]

It sounds like there is an exclusion in your policy for cranial molding orthoses

(the helmet). If Cigna is not willing to have the policy changed, that makes

your job really difficult. You can have all the medical proof, and they can

still refuse to pay. The only other way I know of is to find out if there is a

law to disallow the exclusion. Find out from the insurance company what law

(such as state law) applies to your policy. Then, look up the law and try to

find anything that says insurers must cover birth defects,deformity, etc. Use

that in your appeal. Generally, you must use up all your appeals before you can

appeal to the insurance commissioner. Look up the info for your state, and read

through both the exclusion in your policy and the appeal process. Often, this

info is online on the insurer's website. If not, ask for a copy. Best of luck,

and I hope you can get rid of that exclusion!

>

> Hi, I'm new to this and my son who is 6.5 months old just got his helmet from

Hanger. We went through the pre-authorization process and got denied and the

reason was because my plan simply did not cover it. Cigna told me that I needed

to talk to my employer as they were the one that chose the plan. I contacted my

HR department who told me that they would not do any exceptions and that to go

head and go through the appeal process which I have done and haven't heard back

from Cigna. I don't think at this point Cigna will pay for the helmet as they

are using the reason stated above. Hanger went ahead and submitted the claim

even though Cigna denied it, but I'm trying to get them to reconsider their

decision and pay for the helmet. I got my doctor, nurse, and orthotist to write

a letter to Cigna explaining the reasons why my son needs to wear a helmet.

Cigna also said that my plan would cover it after post operation so my son would

have to go through surgery before they would cover the helmet. This just seems

totally backward to me. I'm not gettinga anywhere with this and was wondering

to know if anyone has gone through the same thing I am and know what I can do to

get the insurance company to pay. My next option is to go to the insurance

commissioner as I'm at a lost at this point. The cost of the helmet was $2200

that we had to pay out of pocket for.

>

> Looking forward to hearing from everyone.

>