NJ prosthetic insurance coverage mandate - anyone heard about this?

[Guest guest]

Our insurance company denied our claim to cover Evan's helmet and we are in the

process of starting an appeal. When I spoke to someone at Cranial Tech for tips,

she mentioned that there is a mandate regarding coverage if the treatment and

your employer are both in NJ. I researched online and found that there is a law

N.J.S.A. 17:48E-35.30 that:

" requires health benefit plans that provide benefits for orthotic and prosthetic

devices to provide coverage for expenses incurred in obtaining orthotic and

prosthetic appliances from any licensed orthotist, prosthetist, or any certified

pedorthist if determined medically necessary by the physician.

When prescribed by the member's physician, eligible appliances may not be

subject to any prior surgery or authorization requirements, medical necessity

determinations and/or utilization management. "

I also found an article (http://www.njbiz.com/article.asp?aID=73338)stating that

" The legislation signed last month requires private health care insurers in New

Jersey, together with the State Health Benefits Program, to cover the cost of

any orthotic or prosthetic device when a doctor deems it medically necessary.

The State Health Benefits Program provides medical, dental and prescription drug

coverage for New Jersey state workers and retirees.

The mandate doesn't allow the insurers themselves to review whether the devices

are medically necessary. Decisions are left solely up to the doctors who refer

patients to orthotists and prosthetists—caregivers who custom build and fit

devices such as leg braces and artificial limbs for patients. The legislation

does not apply to self-funded insurance coverage, typically provided by large

employers. "

Has anyone in NJ heard about this mandate? If what I found is true, why is BCBS

saying that Evan's helmet isn't medically necessary (despite a craniofacial

surgeon saying it is)?