Guest guest Posted June 27, 2004 Report Share Posted June 27, 2004 Howdy, all. I haven't even formally submitted the claim for 's DOC Band, and already I got a denial letter. The letter says that the medical review concluded 's care was appropriate and met community standards, and uses the phrase " elected banding procedure, " implying that it is elective and therefore not necessary. They decline to reimburse me. My big problem is that I don't have a doctor willing to go to bat for me, saying that he recommends a band. 's HMO ped refused to write a prescription because he said if he did, the HMO would have to pay for the band. I had to go outside the system to a referral doc they use and beg her to write the Rx, and she said she wouldn't back me if I tried to get insurance reimbursement. I told her I wasn't going to bother, but now I've changed my mind. The HMO blew him off, and I think it was deliberate, since around here if you don't get the child into treatment before a year, there are no treatment options (only passive bands in Seattle). If the kid can't get treated, the HMO doesn't have to pay. Verrrry convenient for the HMO, no? Anyway, so I don't have a doc to say should have a band. Cranial Tech's measurements put him in the moderate range, and his numbers are about the same as a lot of kids on this board. I think this makes the HMO look even worse, since he was denied care that I was begging for and that other kids with the same condition were given. From what I understand, it isn't up to the peds to override what I want for my child. Right? I mean, it's one thing for an insurance company to deny a claim, but I think it's terrible for a pediatrician to flat-out deny treatment based on money (he was very up front about this)! What do I do now? I'm going to appeal. If anyone has any suggestions for what to say or what paperwork to include, I would be very grateful. I'm a little overwhelmed. , 19 mos, tort, DOC Band 5/7 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 27, 2004 Report Share Posted June 27, 2004 , One more thing I forgot to mention. I have heard of people getting assistance on paying for helmets through Early Intervention (also called Birth To Three is some states). Do you happen to use them for physical therapy for your son's torticollis? If not you might contact them for an evaluation, because in my state (MA) torticollis is a qualifying disorder. We use them for my daughter. I also have contact with some neighbors of my parents in my home state (NY) who have gotten a STAR band paid for through Early Intervention for their child who has tort and plagio. I think you might find in general that toricollis is a diagnosis that is not argued with as much as plagiocephaly is, for some reason. So perhaps you could push for financial support for helmet therapy to solve a problem caused by torticollis. Best of Luck, > > Howdy, all. I haven't even formally submitted the claim for 's > > DOC Band, and already I got a denial letter. > > > > The letter says that the medical review concluded 's care was > > appropriate and met community standards, and uses the phrase " elected > > banding procedure, " implying that it is elective and therefore not > > necessary. They decline to reimburse me. > > > > My big problem is that I don't have a doctor willing to go to bat for > > me, saying that he recommends a band. 's HMO ped refused to > > write a prescription because he said if he did, the HMO would have to > > pay for the band. I had to go outside the system to a referral doc > > they use and beg her to write the Rx, and she said she wouldn't back > > me if I tried to get insurance reimbursement. I told her I wasn't > > going to bother, but now I've changed my mind. The HMO blew him off, > > and I think it was deliberate, since around here if you don't get the > > child into treatment before a year, there are no treatment options > > (only passive bands in Seattle). If the kid can't get treated, the > > HMO doesn't have to pay. Verrrry convenient for the HMO, no? > > > > Anyway, so I don't have a doc to say should have a band. > > Cranial Tech's measurements put him in the moderate range, and his > > numbers are about the same as a lot of kids on this board. I think > > this makes the HMO look even worse, since he was denied care that I > > was begging for and that other kids with the same condition were > > given. From what I understand, it isn't up to the peds to override > > what I want for my child. Right? I mean, it's one thing for an > > insurance company to deny a claim, but I think it's terrible for a > > pediatrician to flat-out deny treatment based on money (he was very > > up front about this)! > > > > What do I do now? I'm going to appeal. If anyone has any suggestions > > for what to say or what paperwork to include, I would be very > > grateful. I'm a little overwhelmed. > > > > > > , 19 mos, tort, DOC Band 5/7 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 27, 2004 Report Share Posted June 27, 2004 , I have read that the key to getting this overturned is that your band is FDA APPROVED. Also, can you contact CT? They might have a database of letters that they can forward on your behalf appealing the denial. I know that I was told by Gillette, the makers of Jaden's CranioCap, that if our ins. denied the claim, that they would write a strong letter urging the insurance that they had to cover it (our ins. paid w/ no problem). You might try contacting Gillette at 1-800-719-4040, and ask for Cheryl, Dr. Wood's nurse for a copy of these letters, or as I said, contact CT. Also, if you are gonna pursue legally, look into a lawyer that would take your case pro bono (no cost to you). It just may very well happen. Good luck, and sorry I couldn't have been more help. ~Amy, mommy to Jaden 7 mo's MN, plagio/mild tort/mild scoliosis, started CranioCap 4/23/04 --- In Plagiocephaly , " tortibaby " <sugrill@j...> wrote: > Howdy, all. I haven't even formally submitted the claim for 's > DOC Band, and already I got a denial letter. > > The letter says that the medical review concluded 's care was > appropriate and met community standards, and uses the phrase " elected > banding procedure, " implying that it is elective and therefore not > necessary. They decline to reimburse me. > > My big problem is that I don't have a doctor willing to go to bat for > me, saying that he recommends a band. 's HMO ped refused to > write a prescription because he said if he did, the HMO would have to > pay for the band. I had to go outside the system to a referral doc > they use and beg her to write the Rx, and she said she wouldn't back > me if I tried to get insurance reimbursement. I told her I wasn't > going to bother, but now I've changed my mind. The HMO blew him off, > and I think it was deliberate, since around here if you don't get the > child into treatment before a year, there are no treatment options > (only passive bands in Seattle). If the kid can't get treated, the > HMO doesn't have to pay. Verrrry convenient for the HMO, no? > > Anyway, so I don't have a doc to say should have a band. > Cranial Tech's measurements put him in the moderate range, and his > numbers are about the same as a lot of kids on this board. I think > this makes the HMO look even worse, since he was denied care that I > was begging for and that other kids with the same condition were > given. From what I understand, it isn't up to the peds to override > what I want for my child. Right? I mean, it's one thing for an > insurance company to deny a claim, but I think it's terrible for a > pediatrician to flat-out deny treatment based on money (he was very > up front about this)! > > What do I do now? I'm going to appeal. If anyone has any suggestions > for what to say or what paperwork to include, I would be very > grateful. I'm a little overwhelmed. > > > , 19 mos, tort, DOC Band 5/7 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 27, 2004 Report Share Posted June 27, 2004 , That ped doesn't sound very ethical to me! To deny treatment to save the HMO money? Is that what I am reading? I would call your state Insurance Commissioner's office and raise a little hell. Natasha --- In Plagiocephaly , " tortibaby " <sugrill@j...> wrote: > Howdy, all. I haven't even formally submitted the claim for 's > DOC Band, and already I got a denial letter. > > The letter says that the medical review concluded 's care was > appropriate and met community standards, and uses the phrase " elected > banding procedure, " implying that it is elective and therefore not > necessary. They decline to reimburse me. > > My big problem is that I don't have a doctor willing to go to bat for > me, saying that he recommends a band. 's HMO ped refused to > write a prescription because he said if he did, the HMO would have to > pay for the band. I had to go outside the system to a referral doc > they use and beg her to write the Rx, and she said she wouldn't back > me if I tried to get insurance reimbursement. I told her I wasn't > going to bother, but now I've changed my mind. The HMO blew him off, > and I think it was deliberate, since around here if you don't get the > child into treatment before a year, there are no treatment options > (only passive bands in Seattle). If the kid can't get treated, the > HMO doesn't have to pay. Verrrry convenient for the HMO, no? > > Anyway, so I don't have a doc to say should have a band. > Cranial Tech's measurements put him in the moderate range, and his > numbers are about the same as a lot of kids on this board. I think > this makes the HMO look even worse, since he was denied care that I > was begging for and that other kids with the same condition were > given. From what I understand, it isn't up to the peds to override > what I want for my child. Right? I mean, it's one thing for an > insurance company to deny a claim, but I think it's terrible for a > pediatrician to flat-out deny treatment based on money (he was very > up front about this)! > > What do I do now? I'm going to appeal. If anyone has any suggestions > for what to say or what paperwork to include, I would be very > grateful. I'm a little overwhelmed. > > > , 19 mos, tort, DOC Band 5/7 Quote Link to comment Share on other sites More sharing options...
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