United Healthcare - Medical Policy Guidelines for plagio helmets

[Guest guest]

I finally have a copy of the UHC guidelines for plagio, after

requesting this since MAY - unfortunately faxed so I don't have it

electronically, but it's what UHC uses to help determine if they're

going to cover your child.

The upshot, which most of us who are fighting them need to know, is

their Coverage Rationale:

Cranial orthotic devices are a reconstructive service for the

treament of craniofacial asymmetry in infants with severe

nonsynostotic plagiocephaly. Cranial orthotic devices are cosmetic

in infants with mild to moderate plagiocephaly.

Clinical considerations: The physician mus provide information that

the infant falls into a high risk group and that functional

impairment such as ocular or oral dysfunction may occur later

because of the persistence of the severe plagiocephaly.

Benefit considerations: When deciding coverage for this service,

the enrollee-specific benefit document language must be referenced.

Most Certificate of Coverage (COCs) and some Summary Plan

Descriptions (SPDs) contain an explicit exclusion from coverage for

orthotic devices.

They do not say what is considered " severe " however, except that

your physician will have to prove a likelihood of ocular or oral

dysfunction. There is a long section of clinical information which

they say is NOT to be used to decide whether or not a service is

paid for. In it, it says " Clinical evidence does not support the use

of cranial orthotic devices in infants with mild to moderate non-

synostotic positional plagiocephaly because of a lack of published

evidence that such infants are at risk for ocular or oral functional

impairment. "

So, if you have UHC, you need to get your doctor to write a letter

that says, specifically, that the plagiocephaly is severe and likely

to cause ocular or oral fuctional impairment. Otherwise it is

unlikely they will pay. My daughter had moderate plagio with ear

involvement, unfortuately this likely will not qualify for

reimbursement.

I will try next week at work to see if I can scan in this document

and save it as a pdf to post.

Good luck to you all, I guess we are out $3750...

Cris in Houston

Mom to - 10 months

DOC Band Grad 7.25.06