How to start appeal process

[Guest guest]

We just got our denial letter in the mail (was expecting it). They denied

because our insurance " doesn't cover cosmetic procedures " . How do I get started

in the appeal process. I know about the files with example letters and such.

Do I call the insurance company? What do I say? Who do I talk to? Since

they're denying for " cosmetic " I shouldn't need a copy of my insurance policy,

should I? Sorry for so many questions. I just don't know the proper procedure.

BTW, I have Anthem BC/BS of VA if that helps any.

Thanks in advance!!

[Guest guest]

Try to find out your insurance company's policy regarding coverage of orthotic

bands/helmets. I found mine by searching the insurance company's website. If you

can't find it, ask for it. It will help you in your argument if you know what

measurements, etc., they are looking for. My insurance company had specific

measurements for cosmetic versus reconstructive. Search around on the internet,

because there are sample appeal letters out there.

I did try to use state law in my argument with my insurance company, but it

didn't work. The message I got read: " Please be advised that as yours is an ASO

account, or self funded national account through your employer, your contract

does not follow state mandate. " I have a BC/BS as well, so you may have the same

problem, but here is some info about the laws, just in case. I looked up the

Virginia insurance laws, and I am not a lawyer, but this is what I understood:

Companies subject to health insurance law in VA cannot exclude coverage for

" congenital anomalies of a covered dependent child. " So, it would help if your

baby was born with the problem and you have some evidence of it. Torticollis,

uterine constriction, head misshapen after birth, complications in delivery that

might have damaged the head/neck. Look back at pictures. I didn't think my baby

was born with it, but I can see it clearly when I go back and look at hospital

pix that he had tort and plagio at birth. Love is blind, after all! If you can

get a doctor to say your child was born with plagio and/or torticollis that

caused the plagio and write a letter that it is a " congenital anomoly, " that

would be a huge help.

There is another section that talks about " cosmetic surgery " and how

reconstructive surgery is not the same and should be covered, especially when it

relates to a congenital anomaly or trauma. I know this is not a surgery, but it

might inspire your wording for your appeal letter. You could argue that the

helmet would help the insurance company avoid paying for a much more expensive

reconstructive surgery, then site this law. Also, you might want to peruse the

laws more and see if you can find anything else about " cosmetic " versus

" reconstructive " treatments.

Make sure you also site the American Medical Association. This is not law, but

it certainly puts some clout behind your argument. They have a statement

regarding " cosmetic " versus " reconstructive. " This is helpful even if your child

was not born with anything because it includes " developmental abnormalies. " You

can use this to argue that the helmet does not meet the definition of a cosmetic

procedure, but is reconstructive.

Another AMA policy specifically says that reconstructive treatments should be

covered even if the function of the body part is not altered. However, many

people argue that plagiocephaly can effect the function of the eyes, jaw, etc.

Here is the Virginia State Law regarding excluding coverage based on the type of

illness (read F1, F5):

http://leg1.state.va.us/cgi-bin/legp504.exe?000+reg+14VAC5-140-60

Here is the Virginia Bureau of Insurance main page:

http://www.scc.virginia.gov/division/boi/

Here are some other appeal letter ideas:

http://www.cappskids.org/cappskids_010.htm

American Medical Association H-475.992 Definitions of " Cosmetic " and

" Reconstructive " Surgery:

https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org & u\

ri=/ama1/pub/upload/mm/PolicyFinder/policyfiles/HnE/H-475.992.HTM

American Medical Association H-185.967 Coverage of Children's Deformities,

Disfigurement and Congenital Defects:

https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org & u\

ri=/ama1/pub/upload/mm/PolicyFinder/policyfiles/HnE/H-185.967.HTM

So your arguements are that it is not a cosmetic treatment, but a reconstructive

treatment for a " congenital anomaly " or for a " developmental abnormality, "

whichever best applies to your situation. By the way, I hope it makes you feel

better to know that I AM getting my helmet covered after some arguing back and

forth, so there is hope! HTH -

>

> We just got our denial letter in the mail (was expecting it). They denied

because our insurance " doesn't cover cosmetic procedures " . How do I get started

in the appeal process. I know about the files with example letters and such.

Do I call the insurance company? What do I say? Who do I talk to? Since

they're denying for " cosmetic " I shouldn't need a copy of my insurance policy,

should I? Sorry for so many questions. I just don't know the proper procedure.

>

> BTW, I have Anthem BC/BS of VA if that helps any.

>

> Thanks in advance!!

>