BCBS Denial in Greenville, SC - advice needed

[Guest guest]

First let me apologize for the length; I'm filling you in on our

appt. today, asking some questions, and also doing some needed

venting! Austin (now 6 months old) had his appointment today at

Orthopedic Services, Inc. in Greenville, SC (which have the

STARband). For any of you in this area, I was very pleased with the

orthotist there; he and one other orthotist specialize in STARbands

and see babies all day every day with this condition. They also

have the star scanner.

Austin scanned in with 15mm assymetry. That qualified as

moderate/severe plagiocephaly with a touch of brachycephaly. He

also was diagnosed with mild torticollis (which his Ped said he

didn't have). Anyway, I had called BCBS before this appointment and

asked how a cranial remolding orthosis would be covered and they

said it was covered 100% of allowable charges as long as we were in-

network, pre-autorization required, and with letter of medical

necessity. When the Orthotists office ran it through while we were

there today it came back that it was not covered AT ALL. I told

them what BCBS had previously told me and the orthotists office said

that BCBS told them that they will cover some off-brand type of

generic passive helmet that is not custom nor active and come in

some generic size small, med. and large, but that was it. They

don't cover anything for an active custom made orthosis. I think

that is a joke. If they cover the cheapo helmet then that means

they recognize the truth in the diagnosis and recognize that it

needs treatment, but won't pay for the real treatment that actually

gives results??!!

We are going to appeal, of course, but one main question I have to

those of you that have already done this is - when a treatment

requires " pre-authorization " such as this would, and I go ahead and

pay up front for the band, start Austin in the band, while we're

going through the appeal process - how do you get around the ins.

co. coming back at you with the fact that you didn't get pre-cert?

Obviously you can't if they deny, but I was wondering if they'll

always have that to hold over your head if you go ahead with

treatment and fight them in the process. Are there any needed

precautions I need to take as far as proceeding without precert but

still appealing? ANY help or suggestions are welcome!

Thank you,

mom to Austin, 6 mos. soon to be STARband

[Guest guest]

Sorry to hear about the frustration you're experiencing. I've heard

of those $600 helmets that are off the shelf, and would be afraid to

put my kid in one. I can't imagine it can help at all.

At least it sounds like you've found a good starband provider. I can't

help you with the appeal info because our starband was covered 100% -

we were very lucky. I hope that you'll get most of your money back on

appeal. I would probably call, tell them you want to treat and plan

to appeal, and see what the process is. There may be a requirement for

something in writing even if it isn't approved.

-christine

sydney 2 yrs starband grad

>

> First let me apologize for the length; I'm filling you in on our

> appt. today, asking some questions, and also doing some needed

> venting! Austin (now 6 months old) had his appointment today at

> Orthopedic Services, Inc. in Greenville, SC (which have the

> STARband). For any of you in this area, I was very pleased with the

> orthotist there; he and one other orthotist specialize in STARbands

> and see babies all day every day with this condition. They also

> have the star scanner.

>

> Austin scanned in with 15mm assymetry. That qualified as

> moderate/severe plagiocephaly with a touch of brachycephaly. He

> also was diagnosed with mild torticollis (which his Ped said he

> didn't have). Anyway, I had called BCBS before this appointment and

> asked how a cranial remolding orthosis would be covered and they

> said it was covered 100% of allowable charges as long as we were in-

> network, pre-autorization required, and with letter of medical

> necessity. When the Orthotists office ran it through while we were

> there today it came back that it was not covered AT ALL. I told

> them what BCBS had previously told me and the orthotists office said

> that BCBS told them that they will cover some off-brand type of

> generic passive helmet that is not custom nor active and come in

> some generic size small, med. and large, but that was it. They

> don't cover anything for an active custom made orthosis. I think

> that is a joke. If they cover the cheapo helmet then that means

> they recognize the truth in the diagnosis and recognize that it

> needs treatment, but won't pay for the real treatment that actually

> gives results??!!

>

> We are going to appeal, of course, but one main question I have to

> those of you that have already done this is - when a treatment

> requires " pre-authorization " such as this would, and I go ahead and

> pay up front for the band, start Austin in the band, while we're

> going through the appeal process - how do you get around the ins.

> co. coming back at you with the fact that you didn't get pre-cert?

> Obviously you can't if they deny, but I was wondering if they'll

> always have that to hold over your head if you go ahead with

> treatment and fight them in the process. Are there any needed

> precautions I need to take as far as proceeding without precert but

> still appealing? ANY help or suggestions are welcome!

>

> Thank you,

>

> mom to Austin, 6 mos. soon to be STARband

>