Guest guest Posted July 18, 2006 Report Share Posted July 18, 2006 Here's my insurance situation: BCBS-FL has denied our appeal so the next step is to file a second-level appeal to the Division of State Group Insurance since the reason for the denial was the fact that this treatment is specifically excluded from my contract (the State Employee's PPO). I spoke on the phone with the person who will make this decision and her only "qualification" is that she is a licensed nurse (NOT a doctor)! If that appeal is denied (which it likely will be) I have the option of requesting an administrative hearing with an "independent" hearing officer (an appointed judge who also happens to be an employee of the State of Florida). I have found a local family who went through this same process last year. They went to the administrative hearing and their case was denied by the judge. The state's "expert witness" was a doctor who is Blue Cross & Blue Shield of Florida's senior medical director. I have been unable to find out what his area of specialization is, but the family I spoke with said that he did not seem familiar with the research he quoted and often contradicted himself. The funny thing here (well, not so funny) is that there were 3 things the judge had to decide: was the cranial orthosis "medically necessary", was it "investigational/experimental" and was it a "cosmetic outcome" (to improve appearance and not function). He found AGAINST the state on the first two (it was medically necessary and was not investigational), but found IN FAVOR OF the state on the last one. Here's the part that I love (NOT!): He said that the evidence presented failed to establish that the treatment was "for correction of a congenital anomaly... while (the child's) torticollis was a congenital anomaly, her deformational plagiocephaly was not, and her DOC band treatment addressed her deformational plagiocephaly, not her torticollis." HUH?!? How can someone separate the two? To my knowledge you can't be born with plagio... but the torticollis, which is congenital, causes it. Just thought this might be of interest to those of you who are also in the process of fighting your insurance companies. I'm SO mad. I still think I'm going to pursue this but in a way I now know it is futile. Alison mom to Leila, born 9/25/05 (tort/plagio, STARband 6/5/06) Boynton Beach, FLWith MSN Spaces email straight to your blog. Upload jokes, photos and more. It's free! It's free! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 18, 2006 Report Share Posted July 18, 2006 In a message dated 7/18/06 11:38:30 AM, amarcof@... writes: To my knowledge you can't be born with plagio... but the torticollis, which is congenital, causes it. Actually, my ortho told me that babys CAN be born w/ plagio - though Tort can cause it and/or make it worse. I know that my dd was born w/ facial asymmetries and they got worse as she got older. We didn't know about "plagio" then. We just knew she "wasn't quite right". Jen Mommy to 4...and 1 more!!!! "Luli" www.babiesonline.com/babies/j/jens5th/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2006 Report Share Posted July 19, 2006 That's a good point-- I guess it's just that the plagio can't really be diagnosed until a bit later as the baby begins to grow (in other words, since most babies who are born vaginally have a rather "funny" head shape, you can't really tell if it's plagio until later when it doesn't just automatically correct itself). What I really think that the judge in the case of this other family's appeal didn't understand was the link between torticollis and plagio. It's taken me a long time to understand it too-- that's why repositioning alone doesn't always work, because if the muscle is still tight from the torticollis it can continue to distort the face and head as the child grows.Alison Plagiocephaly From: DVJen@...Date: Tue, 18 Jul 2006 18:45:55 -0400Subject: Re: insurance woes In a message dated 7/18/06 11:38:30 AM, amarcof@... writes: To my knowledge you can't be born with plagio... but the torticollis, which is congenital, causes it. Actually, my ortho told me that babys CAN be born w/ plagio - though Tort can cause it and/or make it worse. I know that my dd was born w/ facial asymmetries and they got worse as she got older. We didn't know about "plagio" then. We just knew she "wasn't quite right". JenMommy to 4...and 1 more!!!!"Luli"www.babiesonline.com/babies/j/jens5th/ Express yourself instantly with Windows Live Messenger! Windows Live Messenger! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 22, 2006 Report Share Posted July 22, 2006 Alison, don't give up. Sometimes appeals can be pushed through and you seem to have all your info in order. ) Good luck and let us know what the outcome is. Sandy Willow's Mom Tort and plagio resolved 02/04 > > Here's my insurance situation: BCBS-FL has denied our appeal so the next step is to file a second-level appeal to the Division of State Group Insurance since the reason for the denial was the fact that this treatment is specifically excluded from my contract (the State Employee's PPO). > > I spoke on the phone with the person who will make this decision and her only " qualification " is that she is a licensed nurse (NOT a doctor)! If that appeal is denied (which it likely will be) I have the option of requesting an administrative hearing with an " independent " hearing officer (an appointed judge who also happens to be an employee of the State of Florida). > > I have found a local family who went through this same process last year. They went to the administrative hearing and their case was denied by the judge. The state's " expert witness " was a doctor who is Blue Cross & Blue Shield of Florida's senior medical director. I have been unable to find out what his area of specialization is, but the family I spoke with said that he did not seem familiar with the research he quoted and often contradicted himself. > > The funny thing here (well, not so funny) is that there were 3 things the judge had to decide: was the cranial orthosis " medically necessary " , was it " investigational/experimental " and was it a " cosmetic outcome " (to improve appearance and not function). He found AGAINST the state on the first two (it was medically necessary and was not investigational), but found IN FAVOR OF the state on the last one. Here's the part that I love (NOT!): He said that the evidence presented failed to establish that the treatment was " for correction of a congenital anomaly... while (the child's) torticollis was a congenital anomaly, her deformational plagiocephaly was not, and her DOC band treatment addressed her deformational plagiocephaly, not her torticollis. " > > HUH?!? How can someone separate the two? To my knowledge you can't be born with plagio... but the torticollis, which is congenital, causes it. Just thought this might be of interest to those of you who are also in the process of fighting your insurance companies. I'm SO mad. I still think I'm going to pursue this but in a way I now know it is futile. > > Alison > mom to Leila, born 9/25/05 (tort/plagio, STARband 6/5/06) > Boynton Beach, FL > _________________________________________________________________ > Try Live.com - your fast, personalized homepage with all the things you care about in one place. > http://www.live.com/getstarted > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 24, 2009 Report Share Posted February 24, 2009 I was going to suggest the same thing. Call again and ask for the Durable Medical Equipment coverage of a cranial band. I have BC/BS in MA and it's covered fully. I can try to locate the code they used in the claim on my online profile. This is an aside but for those people whose drug/pharmacy coverage does not cover things like Alimentum (which my Medco does not) you can call your insurance and it's typically covered under the Durable Med Equipment up to 1 year if you pay out of pocket and get reinbursed. just and FYI. Ana- On Tue, Feb 24, 2009 at 4:28 PM, <nwilkens2275@...> wrote: THAT is weird. I've never heard of them being lumped in with wigs! That has to be wrong. Which state BCBS do you have? Typically, helmets are included under Durable Medical Equipment as a dynamic orthotic cranioplasty. DME includes braces, walkers, cruches, etc. A lot of times it's denied coverage because they don't cover an device that " changes or reshapes a body part. " It's not a cranial prostheses, it's a cranial orthotic, so there has to be something wrong with the way it was coded when submitted to BCBS. Who submitted your claim? I would check to see what code they used on the claim form, that could make a difference. I have BCBS of NC (FEP, so it could be a little different), but the diagnosis I put on the claim was 754.0 (plagiocephaly) and the description of charge code was S1040 (Cranial Remolding Orthosis), and I'm pretty sure those codes are universal, cause I know others have mentioned them before (I think there's also an L1040 or something like it that is a little different). Anyway, I would definitely look into it further, some people have had success working in conjunction with their HR department as well. I just looked in my BCBS brochure and wigs and other cranial prostheses (which aren't covered) fall under Orthopedic and Prosthetic devices, which helmets are not. They are orthotic, not orthopedic. And on the very next page lists DME and under it says, Continuous Passive Motion (CPM) or Dynamic Orthotic Cranioplasty (DOC) devices, so if your brochure is similar, I think it was billed under the wrong code. Hope that helps! Good luck! Jake-2 (DOCBand Grad 9/08) Jordan-5 > > OUr insurance provider is Blue Cross/Blue Shield and of course we have > been denied coverage for our sons helmet. > > I called and the guy told me it wasn't covered becuase " Wigs, > including cranial prostheses are not covered... " . Are the helmets > considered cranial prostheses??? I am not surprised that they denied > it, and I am going to appeal, but seriously something like this is > included with wigs? > > Robin > Quote Link to comment Share on other sites More sharing options...
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