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.
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.
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.
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.
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.
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!
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.
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.
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.
Hi Andrea email me at [email protected] 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.
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!
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!
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.
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!
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.
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.
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.