insurance appeal

[Guest guest]

I really need to get working on my insurance appeal as I have to submit

it in about a week. Basically my situation is a bit different and if

anyone has done an appeal similar to mine I'd really appreciate any

advice.

I was not denied a helmet/band but Cranial Tech was denied, out of

network coverage as I had in network coverage.

I chose however to go with Cranial Tech instead of the in-network

coverage. So basically I need to prove that they were not good enough

and CT is.

So the typical insurance appeal stuff is not directly relevant to my

situation.

Thanks in advance

Sherry

Chase (6 months)

tort.

DOCband 2/15

[Guest guest]

I really need to get working on my insurance appeal as I have to submit

it in about a week. Basically my situation is a bit different and if

anyone has done an appeal similar to mine I'd really appreciate any

advice.

I was not denied a helmet/band but Cranial Tech was denied, out of

network coverage as I had in network coverage.

I chose however to go with Cranial Tech instead of the in-network

coverage. So basically I need to prove that they were not good enough

and CT is.

So the typical insurance appeal stuff is not directly relevant to my

situation.

Thanks in advance

Sherry

Chase (6 months)

tort.

DOCband 2/15

[Guest guest]

Sherry,

Denial Reasons and Possible Arguments:

1) Out of Network:

a) Determine if there were in-network options within 50 miles. Some insurance companies have a 50-70 miles radius rule. Once you prove you meet the requirements, you get in-network coverage.

Determine if the in-network options are qualified and offer the service needed.

i) Very few orthotic companies offer cranial remolding.

ii) Some offer cranial remolding but see very few patients each month, have no formal/extensive training, or are new to the process.

(1) For comparison the Charlotte, NC Cranial Tech office casts 50-60 new patients each month (per conversation with clinician in Oct 2004).

(2) Cranial Tech requires extensive in house training prior to treating infants. They also do refresher courses each year. They will provide you with the details or check their website, www.cranialtech.com

(3) Does the in-network band have documented research (DOC band does)?

c) Have your dr write the RX for the specific band/helmet you want. Have the dr indicate in the letter of medical necessity why this particular band is required.

i) A very severe case

ii) An after surgery case, currently only DOC band is FDA approved, even though others are used.

iii) A specific headshape that requires special treatment. For example, the scaphocephaly shape is rare and would be best treated by someone with that specific experience.

Have the insurance company check to see if they have any facilities in network that do (wording is important) DYNAMIC ORTHOTIC CRANIOPLASTY.

Hope this helps.

na, 2 1/2 DOC Grad Feb 04, Tort ResolvedKiersten, 8 months, DOC 1.10.06, Tortwww.thefilyaws.com>> I really need to get working on my insurance appeal as I have to submit > it in about a week. Basically my situation is a bit different and if > anyone has done an appeal similar to mine I'd really appreciate any > advice. > > I was not denied a helmet/band but Cranial Tech was denied, out of > network coverage as I had in network coverage. > I chose however to go with Cranial Tech instead of the in-network > coverage. So basically I need to prove that they were not good enough > and CT is. > > So the typical insurance appeal stuff is not directly relevant to my > situation.> > Thanks in advance> > Sherry> Chase (6 months)> tort.> DOCband 2/15>

[Guest guest]

Sherry,

Denial Reasons and Possible Arguments:

1) Out of Network:

a) Determine if there were in-network options within 50 miles. Some insurance companies have a 50-70 miles radius rule. Once you prove you meet the requirements, you get in-network coverage.

Determine if the in-network options are qualified and offer the service needed.

i) Very few orthotic companies offer cranial remolding.

ii) Some offer cranial remolding but see very few patients each month, have no formal/extensive training, or are new to the process.

(1) For comparison the Charlotte, NC Cranial Tech office casts 50-60 new patients each month (per conversation with clinician in Oct 2004).

(2) Cranial Tech requires extensive in house training prior to treating infants. They also do refresher courses each year. They will provide you with the details or check their website, www.cranialtech.com

(3) Does the in-network band have documented research (DOC band does)?

c) Have your dr write the RX for the specific band/helmet you want. Have the dr indicate in the letter of medical necessity why this particular band is required.

i) A very severe case

ii) An after surgery case, currently only DOC band is FDA approved, even though others are used.

iii) A specific headshape that requires special treatment. For example, the scaphocephaly shape is rare and would be best treated by someone with that specific experience.

Have the insurance company check to see if they have any facilities in network that do (wording is important) DYNAMIC ORTHOTIC CRANIOPLASTY.

Hope this helps.

na, 2 1/2 DOC Grad Feb 04, Tort ResolvedKiersten, 8 months, DOC 1.10.06, Tortwww.thefilyaws.com>> I really need to get working on my insurance appeal as I have to submit > it in about a week. Basically my situation is a bit different and if > anyone has done an appeal similar to mine I'd really appreciate any > advice. > > I was not denied a helmet/band but Cranial Tech was denied, out of > network coverage as I had in network coverage. > I chose however to go with Cranial Tech instead of the in-network > coverage. So basically I need to prove that they were not good enough > and CT is. > > So the typical insurance appeal stuff is not directly relevant to my > situation.> > Thanks in advance> > Sherry> Chase (6 months)> tort.> DOCband 2/15>

[Guest guest]

Hi Sherry same is the case with me. Insurance denied Cranial tech and sent us to hanger prosthetics in Torrance,CA.We filed a greivance wih insurance and they came back telling it could not be expedited since it is not a trivial issue. I will be sending them letter of medical necessity and some writeup and articles and see what they come up with.Meanwhile i said a 'go ahead' with the Hanger people as i don't want to wait on things with hope.If they realize, they will pay (or I Pay) for the DOC band as well. R.Tort, 4 months old. Thanks Anilalwell_sherry <type916@...> wrote: I really need to get working on my insurance appeal as I have to submit it in about a week. Basically my situation is a bit different and if anyone has done an appeal similar

to mine I'd really appreciate any advice. I was not denied a helmet/band but Cranial Tech was denied, out of network coverage as I had in network coverage. I chose however to go with Cranial Tech instead of the in-network coverage. So basically I need to prove that they were not good enough and CT is. So the typical insurance appeal stuff is not directly relevant to my situation. Thanks in advance Sherry Chase (6 months) tort. DOCband 2/15 __________________________________________________

[Guest guest]

Hi Sherry same is the case with me. Insurance denied Cranial tech and sent us to hanger prosthetics in Torrance,CA.We filed a greivance wih insurance and they came back telling it could not be expedited since it is not a trivial issue. I will be sending them letter of medical necessity and some writeup and articles and see what they come up with.Meanwhile i said a 'go ahead' with the Hanger people as i don't want to wait on things with hope.If they realize, they will pay (or I Pay) for the DOC band as well. R.Tort, 4 months old. Thanks Anilalwell_sherry <type916@...> wrote: I really need to get working on my insurance appeal as I have to submit it in about a week. Basically my situation is a bit different and if anyone has done an appeal similar

to mine I'd really appreciate any advice. I was not denied a helmet/band but Cranial Tech was denied, out of network coverage as I had in network coverage. I chose however to go with Cranial Tech instead of the in-network coverage. So basically I need to prove that they were not good enough and CT is. So the typical insurance appeal stuff is not directly relevant to my situation. Thanks in advance Sherry Chase (6 months) tort. DOCband 2/15 __________________________________________________

[Guest guest]

I was denied initially as well. They requested a letter of medical

necessity from my nuero-developmental pediatrician and it was approved a

week later...

" jaemegcola "

<jaemegcola@...>

Sent by: cc:

@yaho Subject:

[ ] insurance appeal

ogroups.com

09/06/2006 03:31 PM

Please respond to

My insurance is denying my child speech threrapy under the diagnosis of

verbal apraxia. She must have a congenital anomaly to qualify for

benefits. Is anyone familiar with this struggle, and if so, can you

offer any advice?

[Guest guest]

My child was born with birth defects on his hands and hypospadia

(opening where urine exits in the wrong spot). (An ultrasound showed

he has hydronephrosis; enlarged kidney.) We took him to the

Shriner's in Tampa and they felt he had Streeter's Syndrome

(amniotic band syndrome). From there we went to UCLA and the hand

surgeon/director Dr. Neil Ford felt my son had Poland's

Sequence. When he was 30 mos we took him to a SLP-CCC because he

still wasn't talking. We saw a neurologist and a geneticist and then

United started paying. After we saw our second SLP-CCC and the

neurologist and geneticist was when we had United (before that we

had Aetna HMO).

I am just trying to show that maybe United is paying because my

child has birth defects your doesn't have and that's why they are

paying.

I don't know yet if they are going to pay for OT...

Best wishes,

Debra

> My insurance is denying my child speech threrapy under

the diagnosis of

> verbal apraxia. She must have a congenital anomaly to qualify for

> benefits. Is anyone familiar with this struggle, and if so, can

you

> offer any advice?

>

>

>

>

>

>

> ---------------------------------

> Get your email and more, right on the new .com

>

>

[Guest guest]

Try googling " class action lawsuit humana " I'm battling united

right now. Sounds like they could use a class action lawsuit too,

considering how many are having problems. It's been lots of fun

fighting health insurance and home owners RE: Katrina damage. These

insurance " people " surely will get their own ring in hell, if you

ask me.

>

> I'm having the biggest battle with Humana to pay for my son's

> therapy. They refuse, stating that his problem is an " educational

> delay that will resolve itself. " But none of the doctors or

> therapists or specialists to which I've sent my son seem to think

> that this is an " educational delay, " or that it will " resolve

> itself " .

>

> Humana just doesn't want to pay.

>

> My son has had oral-motor dysfunction since birth, as evidenced by

> the milk coming out of his nose from breastfeeding and the gagging

on

> soft foods, that continues to this day. He was also diagnosed with

> reflux at 4 months. But most striking is the fact that he was

saying

> words before he became ill at 11 months, and then stopped. A year

> after he got out of the hospital, he started speaking again, but

> incomprehensibly. Even words that he was saying before he became

ill

> were markedly different. If you didn't know him, you wouldn't have

> known what he was saying.

>

> I have to exhaust all of my appeals before I can file a lawsuit.

Does

> anyone know of a class action lawsuit going on against Humana? How

> would I find out if one has been filed?

>

[Guest guest]

Look at the procedure codes your professionals are using. We had

Blue Cross and have a 20 session limit per year. My son has

appraxia, aphasia (codes are 784.3,784.69 & 784.5)

Let your PT & OT know your codes for speech/language and not to use

any developmental/educational codes. (just medical necessity).

Insurance battles are fought and won every day but you have

to be persistent. What does their policy state as far

speech therapy? Can you tell me the reason for denial?

Ask for the master policy -they will tell you there is none. They

don't like to give it out -but you need a copy for your appeal.

Physicians are busy - if you need a 'good' letter

quoting research then write it yourself and ask the medical

provider if they would be willing to sign on their

letterhead.

Here is an archived letter from Sandy in Illinois:

SAMPLE LETTER:

[DATE]

VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED

[iNSURANCE CO INFO]

To Whom It May Concern:

My son, __________, has been diagnosed with apraxia by his

pediatrician, his

pediatric neurologist, and his speech and language pathologist.

(See enclosed

information). To remediate this condition, has been

receiving

speech and language therapy as well as occupational therapy (the

apraxia affects

his oral motor musculature as well as his fine and gross motor

functions). His

progress has been excellent, and all concerned believe continued

therapy is

crucial to overcome this condition.

[HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT]

Since apraxia is a relatively uncommon condition, let me explain

briefly what

it is. Apraxia " 'is a neurological disorder that affects the

planning and

production of speech. " (, Jakielski, & Marquardt, 1998)'.[it]

is a loss

in ability to voluntarily position the articulators (e.g., lips,

jaw, tongue)

on a consistent basis when speaking. This disorder interferes with

the child'

s sequencing of sounds into words. In other words, the child has

the ability

to produce the sounds, but when he/she tries to purposefully plan

speech, the

articulators do not always function together properly. " S.

Whitebreak, C.

Dvorak, and K. Jakielsi, " Treatment Effect on Speech Intelligibility

in

Developmental Apraxia of Speech, " Presentation at the American

Speech-Language-Hearing

Association, 1999. " '.This disability has a neurological basis of

unknown

origin. It may reflect neuro-anatomical/physiological differences

that are

inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990;

Shriberg, 1993)

or damage that occurs pre- or postnatally during the period of

speech

development (Crary, 1984; Marquardt and Sussman, 1991). " It is

similar to the

condition stroke victims suffer from when they lose the ability to

speak after a

stroke. In fact, many children initially have speech ability but

then lose it

(as is the case with , who had a larger vocabulary at 18

months of age

than when diagnosed at 25 months of age).

As to medical necessity of treatment of apraxia, the American Speech

Hearing

Association (ASHA) defines verbal apraxia as " a medical condition

consistent

with the definition of illness and disease.'a disorder of body

function.' "

(Keystater, the official publication of the Pennsylvania Speech

Hearing

Language Ass'n, Sept.. 1992; Source: ASHA, Rockville, MD).

Apraxia is not a developmental disorder or delay. If left

untreated, my son

will not develop meaningful speech or coordinated fine and gross

motor

abilities. Lack of meaningful speech and fine and gross motor

abilities would result

directly in a deterioration of my son's health and safety, in that

he will

not be able to communicate medical needs and will be unable to

function and do

daily life skills. With treatment, however, the prognosis is good.

In fact,

_____'s progress has been excellent.

Speech and occupational therapy are the recommended treatments for

apraxia

(see enclosed letters). They are the least expensive, least

invasive, and most

successful forms of treatment, are accepted by the medical

community, and are

not implemented for the convenience of the child or therapist. See

also a

Square, " Introduction, " Clinics in Communication Disorders, 4(2)

( " apraxia

is a motor speech disorder in the ability to regulate and control

oral movement

sequences. Apraxia is a separate speech disorder that requires a

motor

treatment, apraxia is remediable if the clinician knows that this

must be the focus

of treatment " ); Penelope Hall, Jordan and

Robin, " Theory and

Clinical Practices " ( " Intensive services are needed for children

with apraxia "

); Edythe Strand, " Childhood Motor Speech Disorder Treatment, " ( " The

earlier

and more intensive the intervention, the more successful the

therapy.Children

with apraxia really need the intensive individual therapy " ).

In fact, the research indicates and experience dictates that apraxic

children

need intensive consistent therapy. The leading researchers in the

field have

indicated that this is the best therapeutic route to take. Such

researchers

include Edythe Strand, PhD., Mayo Clinic; a Square, Ph.D.,

University of

Toronto; and Robin, Ph.D., University of Iowa. The research

indicates

that the key to success is intensive therapy continually throughout

the year.

In short, since apraxia is a medical condition and not a

developmental delay

or disorder, and since speech and occupational therapy are medically

necessary, I submit that the enclosed expenses should be a covered

benefit under the

plan. Thank you for your consideration.

Sincerely,

contact me privately at mulholland34@... if you have any

questions

All the best,

Joanne