Re: Insurance Appeal - Denied Because of Age

[Guest guest]

I typed a nice, detailed response to you a few days ago and just noticed that it

didn't post for some reason. Doh! So here goes again...

The FDA has approved the DOC Band for children 3-18 months at the start of

treatment, so Aetna doesn't have a leg to stand on with this denial. Cranial

Tech has really good info on their website that you can use in your appeal

letter. The corrected age argument is useful, and I would include it if I were

you, but there are other items you should include as well. I would even number

them in your letter if I were you.

Here's my attempt at an appeal:

The denial of my son's claim for treatment of his deformational plagiocephaly

based on his age of (whatever his age is) is incorrect. I am appealing Aetna's

decision and asking that my son's cranial orthosis be covered based on the

following reasons:

1. My son was born prematurely by 6 weeks, and his corrected age is actually

(whatever his age is). A multitude of medical studies have shown that children

typically develop physically at a rate appropriate for their corrected age.

Therefore, my son has the skull of a (?)-month-old.

2. Since 1998, the FDA has approved the use of the DOC Band for children ages

3-18 months at the beginning of treatment. " The device is assigned the generic

name `cranial orthosis,' and it is identified as a device intended for use on

infants from 3 to 18 months of age with moderate to severe nonsynostotic

positional plagiocephaly, including infants with plagiocephalic-,

brachycephalic-, and scaphocephalic-shaped heads. " ( " FDA Final Rule on the

Classification of Cranial Orthosis, " Federal Register, July 30, 1998) The age

limit of 12 months that Aetna has suggested is not in line with current FDA

guidelines. (Quote from

http://www.cranialtech.com/index.phpoption=com_content & view=

article & id=204:fda-classification & catid=48:manufacturing & Itemid=99)

3. Medical research has shown that DOC Band treatment of children ages 12-18

months is effective. " The Dynamic Orthotic Cranioplasty Band is a cranial

orthotic device used to treat deformational plagiocephaly in infants. The device

works by applying a mild holding pressure to the most anterior and posterior

prominences, where growth is not desired, while encouraging growth in adjacent

flattened regions. Although this technique has been successfully used to treat

infants as young as 3 months of age, it is often assumed that decreasing cranial

growth and increasing cranial rigidity prohibit treatment in infants older than

1 year of age. The authors' experience with older infants suggests the contrary.

Through a series of case reports, they present evidence that this treatment

remains viable during the 2nd year of life and that improvement has been

observed in infants in whom treatment has been initiated as late as 18

months. " (Littlefield TR, Pomatto JK, KM. Neurosurg Focus 9(3): Article 5,

2000)

(Quote from this link: http://thejns.org/doi/pdf/10.3171/foc.2000.9.3.6)

In light of these facts, I expect that Aetna will approve this claim in a timely

manner. As I have shown, timeliness in the treatment of my son's deformational

plagiocephaly is very important, and he is still in the appropriate age range

for treatment. I also expect that Aetna will update coverage guidelines for

cranial orthoses to align with current FDA and medical standards so that future

insureds will not be inconvenienced or incorrectly denied coverage as my son

was.

Thank you for your prompt attention to this matter.

HTH -

>

> Has anyone had any luck appealing with the insurance denial based on age? My

son is covered through Aetna. Their cut off for coverage of the DOC band is 12

months. Unfortunately (after many months of chiropractor repositioning) we moved

a few weeks too late to get the DOC band process started. We are trying to use

the basis that since he was born premature, six weeks early, according to his

Corrected Age, we didn't miss the 12 month cut off. Aetna denied the first

appeal but we are working on the documentation and argument for the second

appeal.

> Any input would be greatly appreciated!

>