Re: Notice of Adverse Determination

[Guest guest]

Hi,

Sorry, I don't know what CAP stands for. What type of band was it

that was denied? I only ask b/c Cranial Tech has a great packet to

help with all specific reasons of appeal. I would search our links

and files section in the meantime to see what you can find. Did you

get a letter of med necessity from a specialist that stated the

possible effects of untreated plagio?

, mom to Hannah, DOCband #3 3/30

Cape Cod, Ma

> Hi! We are in New York and we just got our first denial of

benefits

> from United Health Care's " Empire Plan " . I find this curious,

since

> looking through the database of which insurance companies paid

what,

> UHC seems to have approved as many as they have denied.

>

> My notice of adverse determination states:

>

> " The plan covers recontructive procedures that are performed

> primarlily to improve or restore body function impaired or absent

due

> to a congenital defect, accidental injury, or sickness. Cosmetic

> procedures and treatments are those treatments that improve

> appearance. Benefits are not available for procedures considered

> cosmetic in nature.

>

> I have reviewed the documentation submitted. It has been

determined

> that cranial remolding orthosis is considered cosmetic treatment.

> There is no objective documentation of a physical impairment that

> would be improved or removed by cranial remolding orthosis.

> Therefore, it is considered cosmetic. As a result, no benefits are

> available under the plan for this procedure. "

>

> If that were all, i could just use the ama statement about what is

> cosmetic in nature, and what is not. But, further they state:

>

> In order to successfully appeal they request:

>

> " Documentation to support the existence of a functional impairment

> that would be improved by cranial remolding orthosis. "

>

>

> In our original predetermination request, we submitted a letter

from

> our pediatric neurosurgeon who stated that my son

> experienced " progressive calvarial asymmetry secondary to

positional

> molding. " He also stated that he has moderate-severe deformational

> plagiocephaly, as well as benign familial macrocephaly. He

prescribed

> a cranial orthosis for the calvarial deformity.

>

>

> Now my reason for posting. I have read many posts, articles, web

> sites, where possible results of not treating his plagiocephaly

could

> involve: TMJ, learning disabilities, middle ear infections, vision

> problems. Does anyone know of any actual studies, or statements

made

> by accredited individuals, that I can reference, who have taken

the

> position that these things are definitely associated with

untreated

> plagiocephaly, and that cranial orthosis reduces those occurences?

>

> Also, the doctor who authored the denial letter's name is typed,

> T. Wimit, MD

> Medical Director

> Kingston Service Center

>

> but it is signed:

> T. Wilmit, MD/CAP.

>

> What does CAP stand for?

>

> Sorry for writing a book. Thanks to anyone who can help me!

[Guest guest]

Hello

Sorry to hear that you guys got a denial. Like said you might

find some info in the files / links section that you can use. Also

can you get your neurosurgeon to write you another letter of nec.

Maybe he can also put in this letter problems that can occur of

untreated plagio like the TMJ / ear infections / jaw alignment and

dental problems. Sometimes you would be surprised what docs can do

for you if they want to. Good luck and keep fighting. Let us know

what you can come up with. Also I don't know what CAP stands for,

but usually after the MD which shows what he is would be the job

title. Sorry couldn't answer that ?

Sandy Willow's mom torticollis resolved / CranioGermany Grad / 11m

> Hi! We are in New York and we just got our first denial of

benefits

> from United Health Care's " Empire Plan " . I find this curious,

since

> looking through the database of which insurance companies paid

what,

> UHC seems to have approved as many as they have denied.

>

> My notice of adverse determination states:

>

> " The plan covers recontructive procedures that are performed

> primarlily to improve or restore body function impaired or absent

due

> to a congenital defect, accidental injury, or sickness. Cosmetic

> procedures and treatments are those treatments that improve

> appearance. Benefits are not available for procedures considered

> cosmetic in nature.

>

> I have reviewed the documentation submitted. It has been

determined

> that cranial remolding orthosis is considered cosmetic treatment.

> There is no objective documentation of a physical impairment that

> would be improved or removed by cranial remolding orthosis.

> Therefore, it is considered cosmetic. As a result, no benefits are

> available under the plan for this procedure. "

>

> If that were all, i could just use the ama statement about what is

> cosmetic in nature, and what is not. But, further they state:

>

> In order to successfully appeal they request:

>

> " Documentation to support the existence of a functional impairment

> that would be improved by cranial remolding orthosis. "

>

>

> In our original predetermination request, we submitted a letter

from

> our pediatric neurosurgeon who stated that my son

> experienced " progressive calvarial asymmetry secondary to

positional

> molding. " He also stated that he has moderate-severe deformational

> plagiocephaly, as well as benign familial macrocephaly. He

prescribed

> a cranial orthosis for the calvarial deformity.

>

>

> Now my reason for posting. I have read many posts, articles, web

> sites, where possible results of not treating his plagiocephaly

could

> involve: TMJ, learning disabilities, middle ear infections, vision

> problems. Does anyone know of any actual studies, or statements

made

> by accredited individuals, that I can reference, who have taken

the

> position that these things are definitely associated with

untreated

> plagiocephaly, and that cranial orthosis reduces those occurences?

>

> Also, the doctor who authored the denial letter's name is typed,

> T. Wimit, MD

> Medical Director

> Kingston Service Center

>

> but it is signed:

> T. Wilmit, MD/CAP.

>

> What does CAP stand for?

>

> Sorry for writing a book. Thanks to anyone who can help me!

[Guest guest]

Hi,

NO scientific studies exist that show that cranial molding corrects

any functional impairment.

Studies are just beginning to be published that show functional

problems can be caused by plagio (i.e. astigmatism, sleep apnea,

auditory processing disorders, visual field development problems,

etc.) Even more studies on associated problems will likely need to

be conducted, as well as research cooperation crossing medical

fields, before any studies evaluate how cranial molding

affects/corrects these documented problems.

I think the only way to challenge this appeal is to not take the

carrot of " functional impairment " being dangled by the insurance

company, and completely reject the partnered requirement of showing

that a functional impairment is fixed with the band. They know this

is a dead-end street.

If I were you, I would totally focus on the definition of abnormal

and deformity, and cite the AMA's definitions. You could also use

language proposed in the " Children's Deformities Act of 2003 " Bill i

the House and Senate - check out the link in the LINKS/INSURANCE

folder. This act specifically states that correction of a child's

deformity, even if not resulting in a functional impairment, should

be covered by insurance. I'm not sure where you are going, but did

they provide you with some measurements of your baby's head?

Perhaps you can document that they are however-many deviations off

of the norm. I would think that measurements and photographs would

be extremely helpful. Your md's letter of medical necessity clearly

uses the term deformity.

I don't know what type of orthoses you are using, but perhaps there

are studies out there showing that your brand DOES correct

deformational plagiocephaly.

I wish you the best of luck in your insurance appeal. Hopefully

some info in the LINKS/INSURANCE and LINKS/PLAGIO STUDIES AND

RESEARCH and FILES/INSURANCE sections will be of some help.

Christie (Mom to Repo'd Remy)

> Hi! We are in New York and we just got our first denial of

benefits

> from United Health Care's " Empire Plan " . I find this curious,

since

> looking through the database of which insurance companies paid

what,

> UHC seems to have approved as many as they have denied.

>

> My notice of adverse determination states:

>

> " The plan covers recontructive procedures that are performed

> primarlily to improve or restore body function impaired or absent

due

> to a congenital defect, accidental injury, or sickness. Cosmetic

> procedures and treatments are those treatments that improve

> appearance. Benefits are not available for procedures considered

> cosmetic in nature.

>

> I have reviewed the documentation submitted. It has been

determined

> that cranial remolding orthosis is considered cosmetic treatment.

> There is no objective documentation of a physical impairment that

> would be improved or removed by cranial remolding orthosis.

> Therefore, it is considered cosmetic. As a result, no benefits are

> available under the plan for this procedure. "

>

> If that were all, i could just use the ama statement about what is

> cosmetic in nature, and what is not. But, further they state:

>

> In order to successfully appeal they request:

>

> " Documentation to support the existence of a functional impairment

> that would be improved by cranial remolding orthosis. "

>

>

> In our original predetermination request, we submitted a letter

from

> our pediatric neurosurgeon who stated that my son

> experienced " progressive calvarial asymmetry secondary to

positional

> molding. " He also stated that he has moderate-severe deformational

> plagiocephaly, as well as benign familial macrocephaly. He

prescribed

> a cranial orthosis for the calvarial deformity.

>

>

> Now my reason for posting. I have read many posts, articles, web

> sites, where possible results of not treating his plagiocephaly

could

> involve: TMJ, learning disabilities, middle ear infections, vision

> problems. Does anyone know of any actual studies, or statements

made

> by accredited individuals, that I can reference, who have taken

the

> position that these things are definitely associated with

untreated

> plagiocephaly, and that cranial orthosis reduces those occurences?

>

> Also, the doctor who authored the denial letter's name is typed,

> T. Wimit, MD

> Medical Director

> Kingston Service Center

>

> but it is signed:

> T. Wilmit, MD/CAP.

>

> What does CAP stand for?

>

> Sorry for writing a book. Thanks to anyone who can help me!

[Guest guest]

CAP could mean College of American Physicians or Pathologists.

Good luck on your next appeal. Sounds like you are really doing your

homework.

Crista (Mom to )

> Hi! We are in New York and we just got our first denial of benefits

> from United Health Care's " Empire Plan " . I find this curious, since

> looking through the database of which insurance companies paid

what,

> UHC seems to have approved as many as they have denied.

>

> My notice of adverse determination states:

>

> " The plan covers recontructive procedures that are performed

> primarlily to improve or restore body function impaired or absent

due

> to a congenital defect, accidental injury, or sickness. Cosmetic

> procedures and treatments are those treatments that improve

> appearance. Benefits are not available for procedures considered

> cosmetic in nature.

>

> I have reviewed the documentation submitted. It has been determined

> that cranial remolding orthosis is considered cosmetic treatment.

> There is no objective documentation of a physical impairment that

> would be improved or removed by cranial remolding orthosis.

> Therefore, it is considered cosmetic. As a result, no benefits are

> available under the plan for this procedure. "

>

> If that were all, i could just use the ama statement about what is

> cosmetic in nature, and what is not. But, further they state:

>

> In order to successfully appeal they request:

>

> " Documentation to support the existence of a functional impairment

> that would be improved by cranial remolding orthosis. "

>

>

> In our original predetermination request, we submitted a letter

from

> our pediatric neurosurgeon who stated that my son

> experienced " progressive calvarial asymmetry secondary to

positional

> molding. " He also stated that he has moderate-severe deformational

> plagiocephaly, as well as benign familial macrocephaly. He

prescribed

> a cranial orthosis for the calvarial deformity.

>

>

> Now my reason for posting. I have read many posts, articles, web

> sites, where possible results of not treating his plagiocephaly

could

> involve: TMJ, learning disabilities, middle ear infections, vision

> problems. Does anyone know of any actual studies, or statements

made

> by accredited individuals, that I can reference, who have taken the

> position that these things are definitely associated with untreated

> plagiocephaly, and that cranial orthosis reduces those occurences?

>

> Also, the doctor who authored the denial letter's name is typed,

> T. Wimit, MD

> Medical Director

> Kingston Service Center

>

> but it is signed:

> T. Wilmit, MD/CAP.

>

> What does CAP stand for?

>

> Sorry for writing a book. Thanks to anyone who can help me!