Appealing to United Healthcare to Cover DocBand

Getting your benifits department involved is key! They have a louder voice than you because they can choose whether or not to buy this product again when it terms.

Insurance companies are not concerned with future illness because the odds of you still being covered under UHC in 10 years are rare. People change jobs, employers switch benefits companies...you dont keep one company over your lifetime. So they would be saving someone else money. You need to prove that it will save THEM money NOW by limiting the need for therapy they must pay for, or any other procedure. I dont know what a Doc Band is...but get the company's research on the outcome measures for this product/procedure and any other independent studies done to show why this is necessary.
Letters of medical necessity are necessary first step, but usually not very effective. You are appealing to a nurse or doctor, hired by the insurance company to keep claims down. So a "mom" letter wont help. Your documentation needs to be medically sound and research-based. Know your audience when you're writing. This isn't a bleeding heart medical professional. This is someone who is being paid money to dispute this. So write with that in mind. (That is- once you get into medical review. The initial request needs to be written on a 4th grade level for the first line of reviewers!)
I appeal all the time for my practice- we just dont deal with this specifically, so I dont know the catch phrases they are looking for. If they are excluding "straightening the body", which is weird..what ELSE will this do; ie: what will the side effects of having a straight body be? For instance..now he cant run 50 feet without back pain. After the procedure, he will be able to run without back pain, etc. Dont focus on the "straightening" part. Focus on what the medical outcome will be. You can use reduced risk of future health problems, but that needs to be the last thing mentioned...you need to tel them what the immediate benifit will be. If this is something that can be delayed for 10 years, then they will want yo to delay it so it will be another insurance company's problem.
DOnt be afraid to make it about money, too. This procedure will cost $5. 3 years of therapy will cost $10.
And, if all else fails and you think they are supposed to pay...file a complaint with the Texas department of insurance. It is very easy to do on-line.
Now...if they aren't supposed to pay because your employer specifically excluded these things to save money...then there is nothing you can do. It's like buying fire insurance after your house burns down. If you didn't buy the policy, they dont have to cover it.

2 moms found this helpful

I have twins that are three. We paid for the doc bands and were able to get reimbursed through UHC who administers the self insured plan for my husband. I would be happy to take you through what I did letters I got etc, just send me a private message.

Most insurance companies reject things once or more. The key is proving to them that it's a medical necessity as well as providing documentation that it will save them money in the long run. I'm currently in this process myself. If your doctor's office can't help, work with an individual or organization that can. Contact them and talk to one of their insurance specialists. Don't take one rejection letter and think that's the end of it. Fight the system! The key...showing them they actually save money. Good luck!

I don't have specific experience with DOC Band, but my daughter's arthritis medications are not considered "preventive" and therefore aren't covered under our insurance (also UHC). Without the meds, she will be permanently disabled and could be wheelchair bound, so like you, I don't understand how they can not cover it knowing that the alternative will be more costly in the long-run. As a result, we pay 100% out of pocket until we reach the deductible. We're out thousands a month until we hit the deductible.

Good luck appealing. I haven't tried it, but probably should.

UPDATE: I just saw the response about Scottish Rite. My daughter is a patient there and they are fabulous, but my daughter's meds are not covered. They cover the treatment and lab work costs, which is already a lot given how often we're there, but meds still cost us a small fortune thanks to UHC's policies. I don't know if DOC Band would be covered there or not.

Hi B.,
Just a word of advice before you go down the road of Doc Band...
Our son was 9 months when or Pedi noticed a slight flat spot. When we went to see Cranial Tech they said he was pretty much too old for a Doc Band to do much good - that his head was probably going to stay in that shape because the bones were hardening. We are OK with this because it is SO slight and the measurements were so small. It may be a different case for you guys...But just to make sure your little one isn't being over-treated I would recommend getting a second opinion at the Dell Childrens Cranial-Facial group in Austin, TX. Often times physical therapy for the neck is usually all that is needed. If the baby has developed a pattern to sleep on one side of the head it is a result of, or it produces, a muscular issue that "pulls" the head to that side thus the baby wants to sleep on that side. That's all we did with our son - just neck exercises.

Get a letter of medical necessity from ur peditrician explaining all the risks if it goes without treatment. This worked for us

Hi B.. Sorry if I repeat any info......my oldest had the DOC band 8 years ago. We had United Healthcare at the time. She actually had to have 2 bands because she outgrew the first one and still needed treatment so she needed a second band. It is possible at that age. She got her first one at 7 and half months. Anyway, the people at Cranial Technologies were amazing with the insurance company. They got the bands approved based on the FACT that it's not purely cosmetic. There can be medical issues as well as emotional issues later in life. They got it approved as an Orthotic Device because of potential issues later as a result of the asymmetry. My daughter also had torticollis, or wry neck which I believe is pretty common in babies that need DOC because of the way they hold their head. Just thought I'd mention it in case your baby has it too and maybe it will help with the insurance. Good luck. It's an experience! People look at you like you beat your baby, but embrace it. Take pictures of your baby in his cute little band!

I haven't read through all of your responses so if someone has already suggest this, sorry for the repeat ;-)

When my son was a few months old, we learned he would need a doc-band. Our insurance company (I think it was Aetna at the time) also denied it at first, but I don't remember why. I just know that my husband was able to get them to reverse their decision based on the fact that it was a medical necessity and that is was the ONLY reasonable treatment available not only this area, but period. Basically, we, along with his doctor, made the case that this was the only thing that would help my son, and if he were denied this treatment, it was sure to impact our ( and subsequently the insurance company's) healthcare costs later on. Does that make sense? I'll see if we still have the letter that we sent to them on file, but that was 7 years and two computers ago, so I'm not hopeful. I'll PM you if I have it. HTH!

You need to have your doctor refer you to Scottish Rite hospital for children so that your child can be taken care of there. They are the best of the best in orthopedics and everything there is at no cost because the hospital is fully funded on donations. That way you won't have to deal with insurance at all and your child will recieve the best possible care in the country. People travel from all over the country and even from other countries to go to Scottish Rite, it is amazing!

Hi B.,

We have UHC, too and honestly, I am so grateful to them because they have saved us from financial disaster in the last year. To date, they have paid $1.7 million dollars for my son's health care expenses from a 99 day hospital stay that started 9/8/08. That being said, my son did need a compression glove for his left hand because he has horrible scarring from the drug epinephrine that saved his life but caused terrible skin damage. UHC sees this as an expense related to electable cosmetic surgery so we too had to pay the entire $500+ out of pocket. We've had to make many calls to them in the past year regarding bills and payments and have always found them to be reasonable fair. So, my advice is just follow the steps of appeal, be nice not emotional when talking to reps and hopefully they will see your point and give you what you need.

Hi - My son also had to be banded but luckily our insurance covered it. However, there is a great message board on yahoo health started by mom's of babies w/plagio. They were a God send while my son wore it. Plus, they have great advise on there about working and handling the insurance companies. They'll even provide you the research and documentaion they used in working w/their insurance companies. Here's the link: http://health.groups.yahoo.com/group/AllAboutPlagiocephaly/

Good Luck!

I went through this exact same thing except I was told initially that my insurance (Blue Cross) would cover it 95% if went through Star Cranial. So we opted not to do the Doc band b/c we had hire coverage for an in network provider; so did the Star Band. We paid $600 ( our copay) upfront and went on with the treatment. Got a call from Star Cranial at the end of treatment that our coverage was denied... a little frustrated to say the least considering our upfront expectation. We started the appeal process with Blue Cross - had the medical necessity letter from our pedi, etc. It was denied again and went through my companies benefits department like you are doing. Finally, my company made the ecision to cover after three months of going back and forth. I would just keep trying through your company benefits dpt and appealing. I think they wait for you to give up, to be quite honest. You may have to pay out of pocket; however, I have heard that United will pay and has paid for other patients. Good luck!!

Find out if your company is self-insured - meaning they take the risk for all health claims. If it is self-insured then there is wiggle room for a company to make an exception in your case and provide coverage for this benefit. Enlist your boss, HR, anyone that will listen.

If not, check out devices on the internet. You may be able to purchase it for less.

B.,
Good luck with your quest - we also had a daughter who required the DocBand and had United Health Care at the time. Her pediatrician had prescribed it as medically necessary for a variety of reasons, none of which were cosmetic. This was two years ago, and they advised they would cover the medical services part but not the appliance itself. We were unfortunate to work with Cranial Technologies who absolutely refused to separate the billing for the services from the actual appliance. If you haven't done so yet, I would investigate the possiblity with United and have them recommend alternative sources - I know there is another company out there who does this, but can't remember their name right now. In addition, they are required to cover services for "in network" providers, but don't list a provider for this type of service in the DFW area at all. In that instance, they are supposed to allow you to utilize a facility within 60 miles of your home as "in network"...but again, they refused to do so with us. I may take the involvement of the state board of insurance to get them to cover this in some way. Good luck!

I have not reviewed all your responses but our daughter needed a band. It IS a medically necessary band if in fact it's bad enough. Our daughter was pretty bad. If we had not done the band, it could have affected her facial structure, her teeth and also her ears. She was not "done" with treatment after one band, but our insurance didn't pay for the entire band and we decided a second one wasn't completely necessary for the cost involved. We hoped she would outgrow some of it. Her head will always be WIDER than most but for the most part we're happy with what the first band did for her. After insurance finally approved the first (we didnt' have UHC but had to fight anyhow for ANY coverage), they had no problems covering the second when they saw she was still within the scope of treatment. We just decided not to proceed. I WILL tell you that Cranial Tech has much LIGHTER helmets than Star Cranial Center....if that helps you at all. Easier on the children's necks. Hopefully you won't be in one during the hot summer months. Phew.....they get stinky FAST! :)