UHC Appeal - Policy Exclusion

[Guest guest]

Hello plagio family! My 1 yr old son () is in his second band

and getting better. The first band corrected the asymmetry but I

think the flattening got worse. A month into the second band and

well ... it's sort of rounding out. It gets round, then flat, then

round again. It's hard to describe. We have faith that it will

continue to get better.

Anyways, I am in the middle of a second appeal to UHC regarding a

policy exclusion. After a 20+ page failry comprehensive initial

appeal, I got a 1 page cursory rejection. I have heard through

various support groups that UHC policy exclusion appeals have been

won. Has anyone successfully fought this battle and would you be

willing to share your information. I want to ping them for

discriminating against my child but don't have solid proof ... yet.

That, in addition to my other points, will make a strong argument.

Please help.

Plagiodad

[Guest guest]

Hello,

sorry to see that u r in the same boat as me. I just got my first

denail letter. What reason were they denying your claim?

Thanks

Mark

Where are u going for treatment

-- In Plagiocephaly , " plagiodad " <plagiodad@y...>

wrote:

>

> Hello plagio family! My 1 yr old son () is in his second band

> and getting better. The first band corrected the asymmetry but I

> think the flattening got worse. A month into the second band and

> well ... it's sort of rounding out. It gets round, then flat,

then

> round again. It's hard to describe. We have faith that it will

> continue to get better.

>

> Anyways, I am in the middle of a second appeal to UHC regarding a

> policy exclusion. After a 20+ page failry comprehensive initial

> appeal, I got a 1 page cursory rejection. I have heard through

> various support groups that UHC policy exclusion appeals have been

> won. Has anyone successfully fought this battle and would you be

> willing to share your information. I want to ping them for

> discriminating against my child but don't have solid proof ...

yet.

> That, in addition to my other points, will make a strong argument.

>

> Please help.

>

> Plagiodad

[Guest guest]

Their initial reason was a cosmetic exclusion. They have since

moved to an orthotics policy exclusion. Unfortunately, this is the

most difficult to argue b/c it is an interpretation of fairly

ambiguous verbiage.

I (We) are going to cranial tech in Charlotte.

What is the basis of your denial?

> >

> > Hello plagio family! My 1 yr old son () is in his second

band

> > and getting better. The first band corrected the asymmetry but

I

> > think the flattening got worse. A month into the second band

and

> > well ... it's sort of rounding out. It gets round, then flat,

> then

> > round again. It's hard to describe. We have faith that it will

> > continue to get better.

> >

> > Anyways, I am in the middle of a second appeal to UHC regarding

a

> > policy exclusion. After a 20+ page failry comprehensive initial

> > appeal, I got a 1 page cursory rejection. I have heard through

> > various support groups that UHC policy exclusion appeals have

been

> > won. Has anyone successfully fought this battle and would you

be

> > willing to share your information. I want to ping them for

> > discriminating against my child but don't have solid proof ...

> yet.

> > That, in addition to my other points, will make a strong

argument.

> >

> > Please help.

> >

> > Plagiodad

[Guest guest]

Mark,

I just read your other message. There is some goof info. regarding

the cosmetic / not functional denial. What insurance company do you

use?

> > >

> > > Hello plagio family! My 1 yr old son () is in his second

> band

> > > and getting better. The first band corrected the asymmetry

but

> I

> > > think the flattening got worse. A month into the second band

> and

> > > well ... it's sort of rounding out. It gets round, then flat,

> > then

> > > round again. It's hard to describe. We have faith that it

will

> > > continue to get better.

> > >

> > > Anyways, I am in the middle of a second appeal to UHC

regarding

> a

> > > policy exclusion. After a 20+ page failry comprehensive

initial

> > > appeal, I got a 1 page cursory rejection. I have heard

through

> > > various support groups that UHC policy exclusion appeals have

> been

> > > won. Has anyone successfully fought this battle and would you

> be

> > > willing to share your information. I want to ping them for

> > > discriminating against my child but don't have solid proof ...

> > yet.

> > > That, in addition to my other points, will make a strong

> argument.

> > >

> > > Please help.

> > >

> > > Plagiodad

[Guest guest]

-

Tell them you want a written defination of what their orthotics policy

exclusion is/means. Whatever they DO NOT say, use that in your appeal and

make sure to include the defination they send you in your enclosures. That

way once you have the defination they cannot go back and say, " oh, this

too.... "

>From: " plagiodad " <plagiodad@...>

>Reply-Plagiocephaly

>Plagiocephaly

>Subject: Re: UHC Appeal - Policy Exclusion

>Date: Thu, 28 Oct 2004 12:07:34 -0000

>

>

>Their initial reason was a cosmetic exclusion. They have since

>moved to an orthotics policy exclusion. Unfortunately, this is the

>most difficult to argue b/c it is an interpretation of fairly

>ambiguous verbiage.

>

>I (We) are going to cranial tech in Charlotte.

>

>What is the basis of your denial?

>

>

>

>

> > >

> > > Hello plagio family! My 1 yr old son () is in his second

>band

> > > and getting better. The first band corrected the asymmetry but

>I

> > > think the flattening got worse. A month into the second band

>and

> > > well ... it's sort of rounding out. It gets round, then flat,

> > then

> > > round again. It's hard to describe. We have faith that it will

> > > continue to get better.

> > >

> > > Anyways, I am in the middle of a second appeal to UHC regarding

>a

> > > policy exclusion. After a 20+ page failry comprehensive initial

> > > appeal, I got a 1 page cursory rejection. I have heard through

> > > various support groups that UHC policy exclusion appeals have

>been

> > > won. Has anyone successfully fought this battle and would you

>be

> > > willing to share your information. I want to ping them for

> > > discriminating against my child but don't have solid proof ...

> > yet.

> > > That, in addition to my other points, will make a strong

>argument.

> > >

> > > Please help.

> > >

> > > Plagiodad

>

>

>

_________________________________________________________________

Check out Election 2004 for up-to-date election news, plus voter tools and

more! http://special.msn.com/msn/election2004.armx

[Guest guest]

Hi and welcome to the group,

Is there someone in CT's office than can assist you with this? I

found all of the ammo I needed for my letter here on this site. I

have a different ins. co. than you (IHA, Independent Health) and my

letter is in the Files/Insurance Help section. I had to fight

against the cosmetic and med necess. reasons though.

I'm sure that your letter contained all of the good points and more.

That is a tough one to fight but I look forward to hearing you win!

Did you check the cappkids.org site? I think that is where there was

ins. help and mentioned this one...so it seems that you may possibly

be able to argue that a cranial remolding orthosis is not a piece of

durable medical equipment? Please keep us posted and good luck.

Sue

Colin F., 13 mos.

STARband grad

for brachy

--- In Plagiocephaly , " plagiodad " <plagiodad@y...>

wrote:

>

> Hello plagio family! My 1 yr old son () is in his second band

> and getting better. The first band corrected the asymmetry but I

> think the flattening got worse. A month into the second band and

> well ... it's sort of rounding out. It gets round, then flat, then

> round again. It's hard to describe. We have faith that it will

> continue to get better.

>

> Anyways, I am in the middle of a second appeal to UHC regarding a

> policy exclusion. After a 20+ page failry comprehensive initial

> appeal, I got a 1 page cursory rejection. I have heard through

> various support groups that UHC policy exclusion appeals have been

> won. Has anyone successfully fought this battle and would you be

> willing to share your information. I want to ping them for

> discriminating against my child but don't have solid proof ...

yet.

> That, in addition to my other points, will make a strong argument.

>

> Please help.

>

> Plagiodad

[Guest guest]

Hi Sue. Thanks for the welcome. The folks at the CT office could

have helped with in / out of network. However, they couldn't offer

much with regards to policy exclusions. All of the sample letters

have been GREAT. My initial letter was a combination of several

letters and other research. I searched through old case law for the

federal court of appeals and found some gems for cosmetic denials.

I talked with attorneys that have litigated against insurance

companies for cranial banding. Most are willing to jump on a

cosmetic denial but don't want to be the first to litigate a policy

exclusion case. They could not find any precedent and felt the

insurance companies would fight it to the end. A victory would mean

many new customers for the successful attorney but most aren't

willing to tackle it.

Our policy covers DME but excludes orthotics that reshape body parts

(ie. braces). I am going to keep trying but it is an uphill battle.

I'll keep you posted and thanks for the encouragement. I need it!

> >

> > Hello plagio family! My 1 yr old son () is in his second

band

> > and getting better. The first band corrected the asymmetry but

I

> > think the flattening got worse. A month into the second band

and

> > well ... it's sort of rounding out. It gets round, then flat,

then

> > round again. It's hard to describe. We have faith that it will

> > continue to get better.

> >

> > Anyways, I am in the middle of a second appeal to UHC regarding

a

> > policy exclusion. After a 20+ page failry comprehensive initial

> > appeal, I got a 1 page cursory rejection. I have heard through

> > various support groups that UHC policy exclusion appeals have

been

> > won. Has anyone successfully fought this battle and would you

be

> > willing to share your information. I want to ping them for

> > discriminating against my child but don't have solid proof ...

> yet.

> > That, in addition to my other points, will make a strong

argument.

> >

> > Please help.

> >

> > Plagiodad

[Guest guest]

Use an argument like ... we are not re-shaping a body part but correcting a deformity. If child had a cleft palate surgery would be covered, etc. That exclusion is along the lines of cosmetic issues. Attack it from every way possible.

mom to na

DOC Grad

SCplagiodad <plagiodad@...> wrote:

Hi Sue. Thanks for the welcome. The folks at the CT office could have helped with in / out of network. However, they couldn't offer much with regards to policy exclusions. All of the sample letters have been GREAT. My initial letter was a combination of several letters and other research. I searched through old case law for the federal court of appeals and found some gems for cosmetic denials. I talked with attorneys that have litigated against insurance companies for cranial banding. Most are willing to jump on a cosmetic denial but don't want to be the first to litigate a policy exclusion case. They could not find any precedent and felt the insurance companies would fight it to the end. A victory would mean many new customers for the successful attorney but most aren't

willing to tackle it. Our policy covers DME but excludes orthotics that reshape body parts (ie. braces). I am going to keep trying but it is an uphill battle. I'll keep you posted and thanks for the encouragement. I need it!> > > > Hello plagio family! My 1 yr old son () is in his second band > > and getting better. The first band corrected the asymmetry but I > > think the flattening got worse. A month into the second band and > > well ... it's sort of rounding out. It gets round, then flat, then > > round again. It's hard to describe. We have faith that it will > > continue to get

better.> > > > Anyways, I am in the middle of a second appeal to UHC regarding a > > policy exclusion. After a 20+ page failry comprehensive initial > > appeal, I got a 1 page cursory rejection. I have heard through > > various support groups that UHC policy exclusion appeals have been > > won. Has anyone successfully fought this battle and would you be > > willing to share your information. I want to ping them for > > discriminating against my child but don't have solid proof ... > yet. > > That, in addition to my other points, will make a strong argument.> > > > Please help.> > > > PlagiodadFor more plagio info

[Guest guest]

Hi: I'm fighting UHC for the same reason. The best approach is to proove that the device is not to "reshape" a body part but to "treat an abnormal structure in the baby's skul" and to improve function.

Then, there are plenty of researchs and articles that support this point.

My appeal letter is in one of the folders. Let me know if you need more help.

Ivonne

Mom to

Tort/PlagioBranchy

Banded DOC band Sept 22plagiodad <plagiodad@...> wrote:

Hi Sue. Thanks for the welcome. The folks at the CT office could have helped with in / out of network. However, they couldn't offer much with regards to policy exclusions. All of the sample letters have been GREAT. My initial letter was a combination of several letters and other research. I searched through old case law for the federal court of appeals and found some gems for cosmetic denials. I talked with attorneys that have litigated against insurance companies for cranial banding. Most are willing to jump on a cosmetic denial but don't want to be the first to litigate a policy exclusion case. They could not find any precedent and felt the insurance companies would fight it to the end. A victory would mean many new customers for the successful attorney but most aren't

willing to tackle it. Our policy covers DME but excludes orthotics that reshape body parts (ie. braces). I am going to keep trying but it is an uphill battle. I'll keep you posted and thanks for the encouragement. I need it!> > > > Hello plagio family! My 1 yr old son () is in his second band > > and getting better. The first band corrected the asymmetry but I > > think the flattening got worse. A month into the second band and > > well ... it's sort of rounding out. It gets round, then flat, then > > round again. It's hard to describe. We have faith that it will > > continue to get

better.> > > > Anyways, I am in the middle of a second appeal to UHC regarding a > > policy exclusion. After a 20+ page failry comprehensive initial > > appeal, I got a 1 page cursory rejection. I have heard through > > various support groups that UHC policy exclusion appeals have been > > won. Has anyone successfully fought this battle and would you be > > willing to share your information. I want to ping them for > > discriminating against my child but don't have solid proof ... > yet. > > That, in addition to my other points, will make a strong argument.> > > > Please help.> > > > PlagiodadFor more plagio info