Help with Insurance Appeal for Cranial Banding

Updated on December 15, 2012
A.J. asks from Dallas, TX
35 answers

My 6 1/2 month old son recently was put into a cranial band, "helmet". He has moderate plagiocephaly and torticollis. The insurance company views the cranial band as a "not covered benefit". We have United Healthcare who in the past has been known to change their minds and issue money towards the band. (The bands are $3k, so not cheap) I want to write and appeal and let them know that plagiocephaly is not a cosmetic problem, if not treated it can cause sinus, vision and/or hearing problems as the child develops.

Does anyone have experience with an appeal such as this? If so, what did you do, not do? I'm overwhelmed by this and need some words of wisdom.

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D.W.

answers from Tyler on

the best thing you can do is contact the doctor about this (they do this all the time) and ask the doctor to write a letter stating the medical necessity of this device and to include what can happen if it is not used.

We have to have one of these letters every 6 months for some medicines that my youngest son has to take. That is usually all it will take.

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M.O.

answers from Dallas on

Health Advocate is a company that helps you file appeals and performs follow ups for you. www.healthadvocate.com It was a tedious process; however, we were able to recover several thousand dollars from physical therapy for my son's sensory processing disorder. UHC and Aetna were the two companies that we appealed to.

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A.O.

answers from Dallas on

My son had a DOC band as well. The billing department from the clinic that made the DOC band should be able to help you write the appeal. They run into this all the time.

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S.M.

answers from Dallas on

I see this was written three years ago, but i am having the same problem with the same insurance company. When Cranial Tech called my insurance they denied coverage. I called the insurance company myself and got a much better answer. My daughter's pedi wrote a letter to the Insurance company for approval, so now I'm waiting for the insurance to approve it. The next problem is that Cranial Tech is out of network and there aren't any other providers. If you know of any others please let me know. I heard of one in Waxahachie but can't find the name.

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L.M.

answers from Dallas on

Keep talking to someone(thru Customer Service phone #)at United - keep moving up the chain of command, You don't need to be rude, just insistent and persistent. Your file is notated EACH time you call. It's good to remember when dealing with any type of insurance that it's a contract and depends upon the interpretation of the information UNLESS it is specifically EXCLUDED. You can write to them as well if you prefer to communicate that way. I recommend phone conversation with Health insurance companies - just to get a quicker resolution. I hope you can get something this important covered by your UHC insurance. God bless and don't give up!

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M.S.

answers from Dallas on

Have you talked to the MD office where this was prescribed? They may be able to write a letter of medical necessity. As a nurse we write letters all the time to help families get things covered that have been prescribed and are medically necessary. If this was prescribed by the MD it is obviously medically necessary for the child. Instead of trying to explain it yourself to the insurance company, the MD office should have the appropriate medical language and rationale to support the reason why your child needs this.

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L.N.

answers from Dallas on

It sounds as though your son already has his band, but another thing to consider is that the DOC band is NOT the only company out there. Although we met with the folks at Cranial Tech, we chose to go with another provide who specializes in orthotic/prosthetic devices. Other providers include Hanger and Starband (out of Garland, I believe).

Be sure to look at your network providers to see who is covered. Our provider was in our network so we had an easier time with things.

I agree with the cappskids referral as we also turned to them for additional information.

Good luck...

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T.P.

answers from Dallas on

Hi A. email me at [email protected]____.com on Wednesay as I am out of the office until then I am a manager and i work for UHC and will more than happy to try and look at your case to see what is going on with it. Let me know.

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D.B.

answers from Dallas on

we have UHC...four appeal later and they still denied our claim for the DOC band. I could go on and on about UHC but I won't...I'll be polite. Please email me and I'll be happy to provide you any info you need including a copy of our appeal letter which stated all types of case law. We are out the $3k but no reason anyone else should be : ). I wanted to fight it and sue UHC but my husband just wanted to drop it...we'd spend more in a lawsuit.

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V.T.

answers from Dallas on

While it certainly doesn't hurt for you to write appeal letters, I would highly recommend that you get a letter of medical necessity from your doctor, the technologist that is fitting your son for the band, and possibly even a physical therapist. I am a pediatric physical therapist and have many times written letters of necessity to justify pieces of equipment. Often, insurances put more weight on something coming from a professional with letters behinid their names, so the more people you can get to write letters the better. A doctor (or therapist, you could get a referral for a PT evaluation and then try to get a letter from there) can write a letter and include all the medical jargon and all the problems your child is at risk for that have nothing to do with cosmesis if the skull is not reshaped. Good luck, insurance battles are a pain in the rear, but the squeaky wheel gets the grease!!! The more letters sent, the "squeakier" you become, and hopefully the appeal will be approved.

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M.H.

answers from Dallas on

Hi A., sounds like you have gotten a lot of good advice. Sometimes though, it takes a letter from an attorney to give the extra nudge. I see someone that works with your insurance is going to look at it. If that doesn't work, my husband is an attorney and he is very good at this kind of stuff. He also worked with a medical products company that specialized in surgical and ortho products for the head for 4-5 years. His website is www.haugenlawfirm.com, phone number is ###-###-####. Good luck and God bless you and your little one!

M.

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M.C.

answers from Dallas on

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B.B.

answers from Dallas on

My daughter wore a DOC band and it was covered by my insurance with United Healthcare. They declined the preapproval of the procedure. We decided to go ahead and start the process while we worked on the appeal, accepting the fact we might have to pay. Cranial Technology went ahead and filed the claim before we had a chance to file the appeal. I was pleasantly surprised to recieve the EOB in the mail stating that all costs were covered by insurance. I never called to question it and never filed the appeal. Just in case the appeal is needed, I had collected the following: Articles about adverse conditions caused by plagiocephaly. The best thing to send is a letter from you pediatrician emphasizing the torticollis. Since plagiocephaly can be caused by leaving a child in one position too long, the insurance companies veiw it as a preventable condition, therefore cosmetic to correct. Emphasizing the torticollis will show it was a medical condition that caused the plagiocephaly. I assume you are working with Cranial Technologies. They know how to file the claim. They may want the letter from the doctor to include with the claim. Good luck. Even if I had to pay for the procedure, the DOC band was well worth it. Good luck.

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P.B.

answers from Dallas on

Did you ask the place where he was fitted and placed in the helmet. they should have some ideas or even a letter already written for this

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C.A.

answers from Dallas on

Hi A.,

I agree with finding the Yahoo group - they have great samples and wording for your appeal letter(s). Also, what company did you use to make the helmet? I consulted with Cranial Technologies and they sent me a packet that contained information to help with appeal letters as well.

Good luck in the appeal process!
C.

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J.J.

answers from Dallas on

Have you joined the Yahoo group for Plagiocephaly? There are many moms on there who are very helpful. I remember reading things about United when I was going through it with my son.

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D.L.

answers from Dallas on

Speak to your pediatrician's office, they can help you to word the request properly and give you some hints on how to deal with the insurance company.
My youngest daughter had the band, luckily our insurance covered it. I have heard that a lot of them see it as cosmetic-that is crazy. The other Mom who told you to check on the Yahoo Group was correct, that would be a great resource for you.

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A.C.

answers from Dallas on

I had to appeal to United Healthcare 3 times before they approved a surgery for my daughter this past Christmas. I have written and submitted many appeals to them and would LOVE to help you through this if you'd like my advice. I was lucky enough that by the time I got my child's procedure approved she had grown out of the condition and no longer needed it, however I have been through the entire process and know the ends and outs of it. In fact, with more info I'd be happy to do a bit of research and help write some of it. I am furious with UHC for deciding what a child needs over what the parents and specialists recommend! Just write me a message through Mamasource if you'd like more detailed assistance from me... but for now, here is some basic advice:
1. Go to MYUHC.com and look up how you must submit a claim- they have a specific form you must fill out and attach your personal letters to.
2. Back up everything you have to say with research and try to hold back somewhat on your FEELINGS, they are interested in facts.
3. DO NOT GIVE UP- I think they automatically respond with a no first, maybe twice. They expect you won't keep trying.
4. Mail your appeal from the post office with a return receipt so they can't claim they never received the appeal.

It really isn't very hard to do the appeal itself, the research can be time consuming though. Your doctor might submit an appeal if you request it, but you should still submit your too.

Best of luck- remember to hang in there. It may be a lengthy battle (mine was 6 months) but listen to your heart, not your tired body and weary mind.

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J.S.

answers from Dallas on

I haven't had trouble with that particular appeal, but I have had a lot of trouble with Unicare covering me, saying the Dr.'s were out of network that I went to and the Dr. said they were in network, and they showed up as in network on their website (although they say that they are not accountable for what is on their website...CRAZY). Anyways, I found that it just took fussing and complaining until you get to the right person. I had to go up the chain about 6 people (the first customer service reps and claims agents you speak too are usually very ignorant of matters such as this, don't listen to anything they say, and their supervisors are not much better..it's about the 3rd step up the ladder people are capable and productive..ask for everyones name you talk to, write down the date you talked, time and name of person and notes on conversations) and then I finally got to a person who was able to fix the problem. Also, it is my understanding that if you get the Dr. to write several notes (there is a specific way they word it) that says it is medically necessarry, you might have better luck. I also think calling a Dallas news station with a story like this and then letting them know and try to get them to air the story might be helpful.
We will pray for you and your son.

Christ's Blessings,
J.

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L.S.

answers from San Francisco on

Hello I am sorry to hear about your son. To give you another perspective on your son's condition, gentle chiropractic and cranial work may be an alternative to help your child. My son had plagiocephaly as a baby due to a misalignment of bones in his upper neck from his birth. I didn't know how gentle and effective chiropractic and cranial work could be. It is possible you may find a more effective and affordable treatment with this type of care.

Have a look at the ICPA website and look at some of the research posted, such as this one: http://icpa4kids.org/Chiropractic-Research/chiropractic-c...

Wishing you the best,
L.

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L.H.

answers from Abilene on

Get with your pediatrician and have the insurance manager write a letter of medical necessity. They have experience with these letters and will give more validity to your case. I was an insurance manager for years for an ENT. Don't give up!

L.

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S.

answers from Dallas on

If you are able to have a letter written by an attorney - you might be surprised at how powerful that could be. I know, in a world that made sense (although, such a claim would not be denied in a world of common sense)- a doctor's letter would suffice -- but you know how times are now - the legal letter tends to do the trick. Perhaps that legal stationary just shouts "possible legal action!!!" - and that, of course, is something they want to avoid.

Good luck - Keep fighting!!!! It has always amazed me that parents of children with special needs have to constantly fight the insurance company -- yet men with, uh...difficulties... have their Viagra covered - no questions asked.

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L.N.

answers from Dallas on

Get a note from doctor stating why it is not cosmetic. And Appeal. Also, send a copy to the HR department who handles insurance with your or your hubby's company (who ever the insurance is with). Just keep fighting it and don't give up. I think too many people just accept the denial and the insuance company does not have to pay.
They just seem to make you want to work for it. I have faught several insuarance claims including surgery for my hubby when they did not want to cover some expensive sling aftwards, to rabies vac after my daughter was bitten, to a pediatric surgeon to have a tumor removed. One I even had to appeal twice. But, persistance is the key. Get all documents and keep trying!!
Good Luck, L.

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L.M.

answers from Dallas on

I know that a medication for my daughter wasn't covered and was $500 a month - we just wrote letters - and they approved it!!!! Good luck - I will pray for your little ones needs to be met.

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P.C.

answers from Dallas on

Have your pedi write a detailed letter to be enclosed in your appeal. Be sure to send medical records and all pertinent documents as attachments. You can also file a complaint with the Texas Department of Insurance. Their website will give you instructions. Finally, contact your agent or the personnel in your employer's insurance department. An agent will definitely help you. The personnel in the insurance department probably will as well.

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M.S.

answers from Dallas on

We went through this 6 years ago. Cranial Technologies talked to the insurance company (I think it was United Healthcare but I'm not sure)Anyway, they told them the Doc band was an orthotic device and they paid for it. We had to have 2 because she was so bad and she out grew the first one and they paid for both. Don't give up!

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K.L.

answers from Dallas on

Hi A.,

I work for an insurance co, (not United Healthcare). I have seen these types of appeals and seen them denied. I dont work in the appeals dept but I do work in claims. Its best to have your dr help with the appeal. He/She has to write it in such a way that the insurance co wont think its cosmetic. The doc needs to show what they've already tried and how it did not work and how much the cranial band helps your baby. If there are any specialists involved, letters from them would help as well. Hope I helped you.

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J.M.

answers from Janesville-Beloit on

I see A LOT of people dealing with United Home...has anyone dealt with Dean Health Insurance? A co-worker is currently fighting with them and I will be soon. Just wondering if there's any info anyone can give on working with them.

Updated

I see A LOT of people dealing with United Home...has anyone dealt with Dean Health Insurance? A co-worker is currently fighting with them and I will be soon. Just wondering if there's any info anyone can give on working with them.

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M.C.

answers from Dallas on

I'm currently in the midst of an appeal with my insurance company for a different reason (my DD was in the PICU, and saw an out-of-network doctor there). Is your insurance through your husband's employer? If so, get him to make an appointment with HR to discuss the matter. My husband just talked to HR last week, and they have "extra-special" channels they can go through. As a friend explained it, your insurance company doesn't actually care about you, but they DO care about keeping your husband's company as a customer! The HR rep has also probably seen lots of people through appeals, so can help you out, too. Good luck! Health insurance companies are a pain in the patootie, but it's worth anything to get our kids healthy!

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C.W.

answers from Dallas on

My son had the helmet when he was about the same age as your son. I had Blue Cross/ Blue Shield. They too, denied coverage. My advice is to keep appealing it! I appealed it three times and I came home one day a year later and guess what was in my mailbox! A check for $3000.00. When you appeal it include a letter of necessity from the prescribing doctor, and look up and include all the information you can about why it is medically necessary. I think BC/BS was involved in a lawsuit over the cranial band. You may be able to find info on this on the internet. This would be great to include too! Good luck! My son did great with the helmet! Yours will too!

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B.C.

answers from Dallas on

We also had a child in a "helmet" under United Health Care. Good luck! I worked tirelessly for 6 months attempting to get them to pay for even a portion of it. I was told in the end, that because the "appliance" and service are a bundled price, that they would not cover anything. Cranial Technologies was the company we were referred to by our pediatrician and they would not break out the billing separately - even knowing that the insurance company might pay us something if it was. Our daughter's case was considered a medical necessity, and still we were not able to get a dime from United Healthcare. It was a nightmare. We switch covereage to Blue Cross just prior to her getting her 2nd helmet and they did cover that partially. Some what aggravating since Blue Cross owns United.

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A.T.

answers from Dallas on

You may try to seek support from www.cappskids.org they have alot of information about the condition along with families that have been through the appeal process.

Good luck and don't give up.

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T.D.

answers from Dallas on

My best friend has had the same issue with her son. Same exact situation. She said she has United Health Care, and they will not cover the banding unless it was stated an issue at birth, or is a serious situation. She said you will need a letter from your pediatrian stating at birth your sons condition, one from your banding office, as well as one from your. She said if you go to cranialtech.com, and go to the discussion section, and ask this same question, you might find someone who can help you. She said at the time she did it, only one person won an appeal, and that case was serious. but if you find someone, find out what they wrote in their letters. My friend said it is very unlikly you will win an appeal, but an attorney might help the issue. If you write a letter with all the issues on not fixing this problem would bring........What do you really have to lose in not trying?
Good luck

T.

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K.C.

answers from Dallas on

Ask your doctor to provide a letter of necessity. We had to provide photo documentations and measurements for this procedure.

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M.H.

answers from Dallas on

A.,
Have you ask for assistance from the physician who is treating your son. Typically a letter of medical need from him/her might also help with your appeal. YOu may want to contact his office and see if there is an office manager who can help you.

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