Re: Anthem BCBS Paid for BOTH helmets! This is LONG!

[Guest guest]

What wonderful news Theresa! I can only imagine how thrilled you must have been after fighting for it a whole year! Good for you for sticking it out. Thanks for posting, I know it will definitely be encouraging to all of the members still fighting.

Jen- TXTrentyn- 17 mo. DocBand 06/12/03 & 09/17/03

Anthem BCBS Paid for BOTH helmets! This is LONG!

Hi. I have not posted since July of 02'. Our daughter Jessie wore two DOC bands from 2/02-11/02. She was 11 mos. old when she started and we decided she would wear 2 helmets since she responded so well to the first. We wanted to do all we could for her. At the time, of course, we had no preauthorization from our insurance company and were not willing to wait for it due to our daughter's age when we realized she needed a DOC band. We just pushed forward. Our insurance company, Anthem BCBS of Ohio, refused both bands. They called the first one "experimental/investigational" and the second band "cosmetic". Denial for the second band was overturned after a second appeal. They still, however, denied the first band. This made no sense since the second band was a continuation of treatment of the first band. We went to an external review. They still denied it. Next I filed a complaint w/ the Ohio State Department of Insurance. This was VERY easy to do. I simply called their toll free # and they sent me a one page form asking me to state the nature of my complaint. Along w/ that one page form, I mailed back a VERY thick stack of copies of all the previous correspondence from the first 2 appeals and the external review. This correspondence included letters of denial from Anthem BCBS, my letters for the appeals and external review, medical records from our physical therapist showing Jessie's measurements and improvements(along w/ pictures of her head from start to finish), letters from the neurosurgeon (which by the way I had to call and ask them to write), data from the FDA showing clearance for marketing the DOC band and a ton of articles on the DOC band showing it is proven to work and that it is considered "standard of care". The state department called me after they received everything and shared some very interesting information w/ me. They told me that "...unfortunately, for Anthem BCBS, they did not go through the Ohio State Dept. of Insurance for the external review and that by law, they were required to do so." So, Anthem BCBS had to do another external review. The State Dept. of Ins. would choose who would do the review this time. They chose The Maximus Center for Health Dispute Resolution. They are certified by the State of Ohio Department of Insurance as an Independent Review Organization. The independant physician consultant was familiar w/ the medical management of plagiocephaly. About one month after the State submitted all of this to the new review board, we received a letter from Maximus stating that, "...denial has been reversed." I can't tell you how I was shaking and crying all at the same time. My message to you all is if you have the strength, don't give up. Question everything your insurance company says and does. We would have never known they had not gone through the proper channels for the external review had we not gone throught the state. This took us about a year from when we started the first appeals for both helmets. Please, if I can be of any help to anyone don't hesitate to ask! God Bless you all, especially your little sweethearts. Theresa (mom to Jessie graduated DOC band 11-02.) For more plagio info

[Guest guest]

Well, this is both encouraging and discouraging for me! LOL We have Anthem

BCBS of Virginia... I can only hope and pray that ours gets paid without a

huge long drawn out battle... The good news is the place we're going said

they handle all the insurance stuff for us, at least for now.

Cory in OK

, 6/5/03, casting on 11/12/03

[Guest guest]

I am so happy they paid for both helmets! Also thank you for offering to help others.

Angie and Jenna(STARband grad)

Anthem BCBS Paid for BOTH helmets! This is LONG!

Hi. I have not posted since July of 02'. Our daughter Jessie wore two DOC bands from 2/02-11/02. She was 11 mos. old when she started and we decided she would wear 2 helmets since she responded so well to the first. We wanted to do all we could for her. At the time, of course, we had no preauthorization from our insurance company and were not willing to wait for it due to our daughter's age when we realized she needed a DOC band. We just pushed forward. Our insurance company, Anthem BCBS of Ohio, refused both bands. They called the first one "experimental/investigational" and the second band "cosmetic". Denial for the second band was overturned after a second appeal. They still, however, denied the first band. This made no sense since the second band was a continuation of treatment of the first band. We went to an external review. They still denied it. Next I filed a complaint w/ the Ohio State Department of Insurance. This was VERY easy to do. I simply called their toll free # and they sent me a one page form asking me to state the nature of my complaint. Along w/ that one page form, I mailed back a VERY thick stack of copies of all the previous correspondence from the first 2 appeals and the external review. This correspondence included letters of denial from Anthem BCBS, my letters for the appeals and external review, medical records from our physical therapist showing Jessie's measurements and improvements(along w/ pictures of her head from start to finish), letters from the neurosurgeon (which by the way I had to call and ask them to write), data from the FDA showing clearance for marketing the DOC band and a ton of articles on the DOC band showing it is proven to work and that it is considered "standard of care". The state department called me after they received everything and shared some very interesting information w/ me. They told me that "...unfortunately, for Anthem BCBS, they did not go through the Ohio State Dept. of Insurance for the external review and that by law, they were required to do so." So, Anthem BCBS had to do another external review. The State Dept. of Ins. would choose who would do the review this time. They chose The Maximus Center for Health Dispute Resolution. They are certified by the State of Ohio Department of Insurance as an Independent Review Organization. The independant physician consultant was familiar w/ the medical management of plagiocephaly. About one month after the State submitted all of this to the new review board, we received a letter from Maximus stating that, "...denial has been reversed." I can't tell you how I was shaking and crying all at the same time. My message to you all is if you have the strength, don't give up. Question everything your insurance company says and does. We would have never known they had not gone through the proper channels for the external review had we not gone throught the state. This took us about a year from when we started the first appeals for both helmets. Please, if I can be of any help to anyone don't hesitate to ask! God Bless you all, especially your little sweethearts. Theresa (mom to Jessie graduated DOC band 11-02.) For more plagio info