DENIED

[Guest guest]

first off let me say..sorry so long!!! k, here is where we stand.

they denied us, i appealed, and now we got the denial letter..here is

some good reading for you all..it says:

" the use of dynamic orthotic cranioplasty to treat patients with

nonsynostotic occipital plagiocephaly has been deemed

investigational. current available scientific evidence does not

support conclusions concerning the effectiveness nor medical

necessity of the treatment of the condition referred to as positional

plagiocephaly. our denial was based on the treatment as being not

medically necessary as there is no functional impairment. under the

limitations and exclusions section fo the plan, there are no benefits

for treatment of a congenital disease or anamaly except to correct a

funtion (underlined) defect...the plan does not provide benefits for

services not medically necessary for diagnosis and tretment of an

injury or sickness. medically necessary is defined in the plan

as " the extent of services required to diagnose or treat an injury or

sickness which is known to be safe, effective and approriate by most

qualified practitioners who are licensed to treat that injury or

sickness. such services must be performed in the least costly setting

required by the patients condition and must not be proviede primarily

for the convenience of the patient, the patient's family or the

qualified practitioner " it is well known that positional

plagiocephaly due to torticollis can be successfully treated by

positional rotation combined with activae and passive stretching

excercises. in addition, positional plagiocephaly is not associated

with funcional impairment. also, because the use of doc headband is

still investigational, under the limitations and exclusions section

of the plan, the plan does not provide benefits for any medical or

surgical procedure, which is considered experimental or

investigational....based on the limitations and exclusions of the

plan, the doc headband was denied because this treatment is

considered not medically necessary, investigational and because there

is no documented funtional impairment..if you have further questions

or would like to appeal or decision, please feel free to write your

local american arbitration association..

so that is the letter...long huh..and i even cut some stuff out!!

HELP..what do i do..p.s..i hope they werent refering to my son when

they said torticollis because he don't have it..at least i was never

told he did..

so..what do you all think...maybe the doc clinic people can help!!

[Guest guest]

Your insurance co. doesn't cover durable medical equipment at all? I

have heard of a couple of persons getting the bands covered by United

HealthCare (I'm not if it is the same division of United HealthCare -

I don't know if they differ state to state). You might want to go to

www.cappskids.org and look up i under plagio kids. Her mother,

Jaya Dong, was successful in appealing United HealthCare's denial, I

believe in New York state. She has a link to contact her or you can

go to the other board on plagiocephaly that can be accessed

thru her site and ask her there. Good luck.

Candy, mom to (DOCbanded 10/5/01)

land

> I just heard from our pediatrician that Dane's DOC Band was denied

> by United Healthcare. Our policy doesn't cover orthotics, so we

> can't even appeal.

> What aggravates me is that I called 5 or 6 times and was told it

> would be covered with appropriate documentation. I spent $40 in

> courier fees. I wanted to have a receipt that someone actually

> signed for the documents and they couldn't say they were lost. The

> thing I feel the worst about is that I wasted the doctor's time.

> She did research and stayed until 10 or 11 one night writing this

> letter. My friend is an insurance agent and she said it seems that

> the job of the Customer Service Reps is just to get you off the

> phone. They have the disclaimer when you are on hold that says

> whatever is said in the conversation doesn't ensure coverage. Why

> am I calling if they are held to what they are saying? Why bother

> calling at all?

> Time to change insurance plans! We are still going through with the

> DOC Band. I don't care how much it costs. He shouldn't have to go

> through life with a lopsided face.

> Sorry for rambling.

>

> Dane's mom