Re: Independent Health INTERNAL APPEAL RESULT

[Guest guest]

Yippee!!! That is the best news. Thanks for sharing this. It will help

others for sure.

Angie and Jenna

Independent Health INTERNAL APPEAL RESULT

> I will tell you that it was THEE single most nerve-wracking

> experience of my entire life EVER! I was led into a small room of 4

> male medical dr.'s (HMO med dir's and community physicians - 1 of

> which was a ped) and a couple of women (nurse case mgrs). I thought

> my heart was going to fall out of my chest. I asked if I could tape

> record the mtg. and the nurse manager woman said that she did not

> know I wanted to do that and would have to call their legal dept. I

> said that was fine so I had to leave the room while they (supposedly)

> called. When I came back they said that I could take notes but legal

> said that I could not record the conversation (something about

> signing HIPAA things maybe?). I was told that they all reviewed my

> letter and supporting documents (I put it in the FILES section on

> this site) and that I could take about 10 minutes to discuss why I

> thought that Colin's band was not being used for COSMETIC reasons.

>

> I pulled out a large photo of him wearing the band and first said

> that no parent would ever want their child to wear this on their head

> for 23 hrs. a day for cosmetic reasons only. Then I read a part of

> the neurosurgeon's letter that he wrote to Colin's primary ped saying

> that he believed that Colin would benefit from cranial helmet

> therapy; that he reviewed photos of Colin from 3 mos. of age to the

> present and that no significant improvement has been seen. I think

> I muttered something about the AMA Resolution 119 about cosmetic vs.

> reconstructive therapies and the children's disfigurement and

> deformity bill. I showed them the Starscanner report showing that

> Colin's measurements were in the severe range and I read Aetna's

> policy for covering the band saying that Colin met their criteria.

>

> When I was finished one of the community physician's asked if I had

> any photos of Colin with me to show them. I only had the

> Starscanner computer profile picture so I showed them that. He asked

> me something else that I cannot remember but I believe that I

> answered it well. One medical director of IHA said that " I was a good

> advocate. "

>

> I was told that I would be called the next day (today) and I thought

> at the time that I would get the denial reversed. I really think

> that they had already made up their minds before I even pleaded my

> case but who knows.

>

> I just received a call from the nurse. She asked to verify Colin's

> DOB and address (which made me nervous, I was trying to read her tone

> of voice). She said they have reversed the denial and we have

> authorization!!!!! WoooHooooo! I am SO HAPPY! She did reprimand me

> again for going out-of-network without pre-approval (the orthotist).

> Our rider is 50% coverage up to $1000/yr. so I am assuming we are

> getting $1000. I'll take it!!! Now that I'm a pro at this (HAHAHA!)

> I may quit my job and travel the country to help anyone else out.

> Seriously, if you have to do this, just do your homework and use all

> the references you can find and you CAN WIN!

>

> THANK YOU to all of those that have contributed to the insurance help

> files and thank you all for being here for me and Colin!!!

>

> Sue (doing a seriously funky-looking happy dance)

> and

> Colin F. 9.5 mos., brachy, rt plagio, STARband 6/29

> Buffalo, NY

>

>

>

>

> For more plagio info

[Guest guest]

I am soo happy for you Sue, you've got guts girl!! It's so nice to hear that we can use our information and put it to good use. I can almost picture you there, I can imagine that they would want you to be very intimidated so that you would perhaps back down. They must of thought you were pretty darn serious to mention taping it as well. Kudos to you, thanks for sharing, I was thinking of you.

and Angelina in Canada

-----Original Message-----From: sueandcolin2004 [mailto:justsue5@...]Sent: Friday, July 16, 2004 9:18 AMPlagiocephaly Subject: Independent Health INTERNAL APPEAL RESULTI will tell you that it was THEE single most nerve-wracking experience of my entire life EVER! I was led into a small room of 4 male medical dr.'s (HMO med dir's and community physicians - 1 of which was a ped) and a couple of women (nurse case mgrs). I thought my heart was going to fall out of my chest. I asked if I could tape record the mtg. and the nurse manager woman said that she did not know I wanted to do that and would have to call their legal dept. I said that was fine so I had to leave the room while they (supposedly) called. When I came back they said that I could take notes but legal said that I could not record the conversation (something about signing HIPAA things maybe?). I was told that they all reviewed my letter and supporting documents (I put it in the FILES section on this site) and that I could take about 10 minutes to discuss why I thought that Colin's band was not being used for COSMETIC reasons. I pulled out a large photo of him wearing the band and first said that no parent would ever want their child to wear this on their head for 23 hrs. a day for cosmetic reasons only. Then I read a part of the neurosurgeon's letter that he wrote to Colin's primary ped saying that he believed that Colin would benefit from cranial helmet therapy; that he reviewed photos of Colin from 3 mos. of age to the present and that no significant improvement has been seen. I think I muttered something about the AMA Resolution 119 about cosmetic vs. reconstructive therapies and the children's disfigurement and deformity bill. I showed them the Starscanner report showing that Colin's measurements were in the severe range and I read Aetna's policy for covering the band saying that Colin met their criteria. When I was finished one of the community physician's asked if I had any photos of Colin with me to show them. I only had the Starscanner computer profile picture so I showed them that. He asked me something else that I cannot remember but I believe that I answered it well. One medical director of IHA said that "I was a good advocate."I was told that I would be called the next day (today) and I thought at the time that I would get the denial reversed. I really think that they had already made up their minds before I even pleaded my case but who knows.I just received a call from the nurse. She asked to verify Colin's DOB and address (which made me nervous, I was trying to read her tone of voice). She said they have reversed the denial and we have authorization!!!!! WoooHooooo! I am SO HAPPY! She did reprimand me again for going out-of-network without pre-approval (the orthotist). Our rider is 50% coverage up to $1000/yr. so I am assuming we are getting $1000. I'll take it!!! Now that I'm a pro at this (HAHAHA!) I may quit my job and travel the country to help anyone else out. Seriously, if you have to do this, just do your homework and use all the references you can find and you CAN WIN!THANK YOU to all of those that have contributed to the insurance help files and thank you all for being here for me and Colin!!!Sue (doing a seriously funky-looking happy dance)andColin F. 9.5 mos., brachy, rt plagio, STARband 6/29Buffalo, NYFor more plagio info

[Guest guest]

Sue -

I am so HAPPY for you!!!!!YIPPPPEEEEE!!!!! AND.... I am also so proud

of you - You did the right thing and stood up for your son! What

FANTASTIC news!!!! I could picture you talking and your tone of voice.

You are right when you say, " no parent would ever want their child to

wear this on their head for 23 hrs. a day for cosmetic reasons only. "

Isn't that the truth. I just don't understand these insurance companies

that think Plagio. is just not a BIG deal. How emotional is ALL of

this? When I went to talk to a nurse, she said the Ped. on staff said,

" Plagio is just cosmetic " . I said to her, " Plagio is considered an

ABNORMALITY - I think if this Ped. had a child with Plagio. he would

not just take it as lightly " . She agreed. I am so glad you stuck it

out and fought the right for coverage!

Krissy

ph's mom

Starband 4/28/04 (7 months)

Palm Harbor, FL

On Jul 16, 2004, at 12:18 PM, sueandcolin2004 wrote:

> I will tell you that it was THEE single most nerve-wracking

> experience of my entire life EVER! I was led into a small room of 4

> male medical dr.'s (HMO med dir's and community physicians - 1 of

> which was a ped) and a couple of women (nurse case mgrs). I thought

> my heart was going to fall out of my chest. I asked if I could tape

> record the mtg. and the nurse manager woman said that she did not

> know I wanted to do that and would have to call their legal dept. I

> said that was fine so I had to leave the room while they (supposedly)

> called. When I came back they said that I could take notes but legal

> said that I could not record the conversation (something about

> signing HIPAA things maybe?). I was told that they all reviewed my

> letter and supporting documents (I put it in the FILES section on

> this site) and that I could take about 10 minutes to discuss why I

> thought that Colin's band was not being used for COSMETIC reasons.

>

> I pulled out a large photo of him wearing the band and first said

> that no parent would ever want their child to wear this on their head

> for 23 hrs. a day for cosmetic reasons only. Then I read a part of

> the neurosurgeon's letter that he wrote to Colin's primary ped saying

> that he believed that Colin would benefit from cranial helmet

> therapy; that he reviewed photos of Colin from 3 mos. of age to the

> present and that no significant improvement has been seen. I think

> I muttered something about the AMA Resolution 119 about cosmetic vs.

> reconstructive therapies and the children's disfigurement and

> deformity bill. I showed them the Starscanner report showing that

> Colin's measurements were in the severe range and I read Aetna's

> policy for covering the band saying that Colin met their criteria.

>

> When I was finished one of the community physician's asked if I had

> any photos of Colin with me to show them. I only had the

> Starscanner computer profile picture so I showed them that. He asked

> me something else that I cannot remember but I believe that I

> answered it well. One medical director of IHA said that " I was a good

> advocate. "

>

> I was told that I would be called the next day (today) and I thought

> at the time that I would get the denial reversed. I really think

> that they had already made up their minds before I even pleaded my

> case but who knows.

>

> I just received a call from the nurse. She asked to verify Colin's

> DOB and address (which made me nervous, I was trying to read her tone

> of voice). She said they have reversed the denial and we have

> authorization!!!!! WoooHooooo! I am SO HAPPY! She did reprimand me

> again for going out-of-network without pre-approval (the orthotist).

> Our rider is 50% coverage up to $1000/yr. so I am assuming we are

> getting $1000. I'll take it!!! Now that I'm a pro at this (HAHAHA!)

> I may quit my job and travel the country to help anyone else out.

> Seriously, if you have to do this, just do your homework and use all

> the references you can find and you CAN WIN!

>

> THANK YOU to all of those that have contributed to the insurance help

> files and thank you all for being here for me and Colin!!!

>

> Sue (doing a seriously funky-looking happy dance)

> and

> Colin F. 9.5 mos., brachy, rt plagio, STARband 6/29

> Buffalo, NY

>

>

>

>

> For more plagio info

[Guest guest]

Oh, I think insurance companies are all about not having to spend their

precious money. They're all about the bottom line. And they'll use

any justification to delay and/or deny payment.

Jocelyn

Krissy Cook wrote:

Sue -

I am so HAPPY for you!!!!!YIPPPPEEEEE!!!!! AND.... I am also so proud

of you - You did the right thing and stood up for your son! What

FANTASTIC news!!!! I could picture you talking and your tone of voice.

You are right when you say, "no parent would ever want their child to

wear this on their head for 23 hrs. a day for cosmetic reasons only."

Isn't that the truth. I just don't understand these insurance

companies that think Plagio. is just not a BIG deal. How emotional is

ALL of this? When I went to talk to a nurse, she said the Ped. on

staff said, "Plagio is just cosmetic" . I said to her, "Plagio is

considered an ABNORMALITY - I think if this Ped. had a child with

Plagio. he would not just take it as lightly". She agreed. I am so

glad you stuck it out and fought the right for coverage!

Krissy

ph's mom

Starband 4/28/04 (7 months)

Palm Harbor, FL

On Jul 16, 2004, at 12:18 PM, sueandcolin2004 wrote:

I will tell you that it was THEE single most

nerve-wracking

experience of my entire life EVER! I was led into a small room of 4

male medical dr.'s (HMO med dir's and community physicians - 1 of

which was a ped) and a couple of women (nurse case mgrs). I thought

my heart was going to fall out of my chest. I asked if I could tape

record the mtg. and the nurse manager woman said that she did not

know I wanted to do that and would have to call their legal dept. I

said that was fine so I had to leave the room while they (supposedly)

called. When I came back they said that I could take notes but legal

said that I could not record the conversation (something about

signing HIPAA things maybe?). I was told that they all reviewed my

letter and supporting documents (I put it in the FILES section on

this site) and that I could take about 10 minutes to discuss why I

thought that Colin's band was not being used for COSMETIC reasons.

I pulled out a large photo of him wearing the band and first said

that no parent would ever want their child to wear this on their head

for 23 hrs. a day for cosmetic reasons only. Then I read a part of

the neurosurgeon's letter that he wrote to Colin's primary ped saying

that he believed that Colin would benefit from cranial helmet

therapy; that he reviewed photos of Colin from 3 mos. of age to the

present and that no significant improvement has been seen. I think

I muttered something about the AMA Resolution 119 about cosmetic vs.

reconstructive therapies and the children's disfigurement and

deformity bill. I showed them the Starscanner report showing that

Colin's measurements were in the severe range and I read Aetna's

policy for covering the band saying that Colin met their criteria.

When I was finished one of the community physician's asked if I had

any photos of Colin with me to show them. I only had the

Starscanner computer profile picture so I showed them that. He asked

me something else that I cannot remember but I believe that I

answered it well. One medical director of IHA said that "I was a good

advocate."

I was told that I would be called the next day (today) and I thought

at the time that I would get the denial reversed. I really think

that they had already made up their minds before I even pleaded my

case but who knows.

I just received a call from the nurse. She asked to verify Colin's

DOB and address (which made me nervous, I was trying to read her tone

of voice). She said they have reversed the denial and we have

authorization!!!!! WoooHooooo! I am SO HAPPY! She did reprimand me

again for going out-of-network without pre-approval (the orthotist).

Our rider is 50% coverage up to $1000/yr. so I am assuming we are

getting $1000. I'll take it!!! Now that I'm a pro at this (HAHAHA!)

I may quit my job and travel the country to help anyone else out.

Seriously, if you have to do this, just do your homework and use all

the references you can find and you CAN WIN!

THANK YOU to all of those that have contributed to the insurance help

files and thank you all for being here for me and Colin!!!

Sue (doing a seriously funky-looking happy dance)

and

Colin F. 9.5 mos., brachy, rt plagio, STARband 6/29

Buffalo, NY