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.
Hi Andrea, 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 972-436-8750. Good luck and God bless you and your little one!
Maggie
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, Lauren
Hi Andrea,
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.
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
tina
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.
Andrea,
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.
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.
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.
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.
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!
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.
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.
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-care-of-an-infant-with-plagiocephaly.html
Wishing you the best,
Lorraine
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.
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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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.