Guest guest Posted February 12, 2001 Report Share Posted February 12, 2001 Darrin, We have an HMO (Healthcare Oklahoma) as well, and we have been through the entire appeals process and I would say document, document, document. You need to write down EVERYTHING that occurs. Every phone conversation, fax, correpsondance, etc. At the end of the appeals process our HMO is still saying it is not covered due to being cosmetic despite three letters of medical necessity from ped and neuro. What is the reason they are giving for non-coverage? We are getting ready to take our HMO to small claims court and hopefully everything will end there. There is some good information on the internet regarding plagio - on the plagio group homepage there is a " links " option that can hook you up with some information. There is also a folder with " insurance help " that has several excellent appeals letters that were successful. I hope this helps! Marci (Mom to ) Norman, Oklahoma Go Sooners!!! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 12, 2001 Report Share Posted February 12, 2001 Darrin: I have a letter under the FILES section in the insurance help that had a successful appeals to CIGNA (HMO at the time) -- it is a combination of many wonderful letters, some provided by Cranial Technologies, some by parents from this board, and I geared it to our specific situation. I found CIGNA to be QUITE evasive -- telling me it the DOC would be covered, then telling me it wouldn't. I got all kinds of different answers orally, but I learned (too late) to GET THINGS IN WRITING. Even if it means by fax. One day I was on the phone with them for TWO hours trying to get answers, and every one of the extensions and names I got were not able to be "reached" the next day. Take everything down!! Try to get as much in writing as you can. Once any insurance company denies you in writing, they cannot change the reason -- for example, if they only give you one reason such as it's "cosmetic" and then in another letter tell you it's because you didn't try enough reposositioning, etc., they are not allowed to do that. However, that means that your initial denial letter will probably have several reasons -- ours had 4 "reasons" for denial, which we just matter-of-factly spit back at them with logical examples why they weren't true. I'm sure others will have some suggestions for you too -- but if you have any other questions that aren't answered, please feel free to write me at tnt@... and I'll do the best I can. Good Luck! H in Ohio Mom to Quinn (aka "Kali") -----Original Message-----From: Darrin [mailto:imasoonerfan@...]Sent: Monday, February 12, 2001 12:49 AMPlagiocephaly Subject: What to expect?My wife, Suzette, and I just found out a couple of weeks ago that our daughter, Carly, has been diagnosed with Posterior Plagiocephaly. Our doctor prescribed the STAR band. We contacted our insurance company, Cigna HMO and were told it was covered. We were set to have it fit when the day before we were told by Cigna "sorry this is not covered under your plan." Right now we have started the appeals process and are being told by a supervisor at Cigna it is covered and Health Services it is not. What can we expect from the appeals process? How many people have been successful with Cigna? Darrin Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 12, 2001 Report Share Posted February 12, 2001 Darrin, We, too, had CIGNA insurance and got the run-around from them. The doctor called to get authorization for the band and CIGNA denied them over the phone. When I called they said it would be covered under " durable medical equipment " but only the first $1000. Then they denied in writing, for cosmetic reasons. The doctor's office sent them a ton of information and another request, and this time they denied on the basis of it " not being covered under the plan " and being " experimental. " Anyway, we were allowed one more appeal, and this time we won. Our letter is posted in the files section on the plagio site. We addressed both the experimental and cosmetic reasons for denial, although my understanding is that they can't deny for two different reasons. At this point, we are just glad that they ended up paying! Good luck in your fight, and if I can be of any further help, please email me. Wendi & (DOC band graduate) cwlkjbastian@... On Mon, 12 Feb 2001 05:48:37 -0000 " Darrin " <imasoonerfan@...> writes: > My wife, Suzette, and I just found out a couple of weeks ago that our > > daughter, Carly, has been diagnosed with Posterior Plagiocephaly. > Our doctor prescribed the STAR band. We contacted our insurance > company, Cigna HMO and were told it was covered. We were set to > have > it fit when the day before we were told by Cigna " sorry this is not > > covered under your plan. " Right now we have started the appeals > process and are being told by a supervisor at Cigna it is covered > and > Health Services it is not. What can we expect from the appeals > process? How many people have been successful with Cigna? > > Darrin > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 12, 2001 Report Share Posted February 12, 2001 Darrin, I just got off the phone cancelling my son's casting appt. for this morning. I also have Cigna HMO and am getting the run around from them. They guarantee they will have an answer for me by tomorrow. I have a feeling it will be no but I rescheduled my casting appt. for Fri. My husband and I decided we are not waiting any longer. I will try to appeal but I believe that takes a long time and with getting appts., insurance, etc. we have already wasted over 2 months. I don't have an answer for you I just wanted you to know we are going through it too!!! Please let me know what your ins. says. Good luck!! Tami----- Original Message ----- From: Darrin <imasoonerfan@...> <Plagiocephaly > Sent: Sunday, February 11, 2001 9:48 PM Subject: What to expect? > My wife, Suzette, and I just found out a couple of weeks ago that our > daughter, Carly, has been diagnosed with Posterior Plagiocephaly. > Our doctor prescribed the STAR band. We contacted our insurance > company, Cigna HMO and were told it was covered. We were set to have > it fit when the day before we were told by Cigna " sorry this is not > covered under your plan. " Right now we have started the appeals > process and are being told by a supervisor at Cigna it is covered and > Health Services it is not. What can we expect from the appeals > process? How many people have been successful with Cigna? > > Darrin > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2001 Report Share Posted February 21, 2001 Hi Marci and everyone- We have our appointment 1 week from today to evaluate my son's degree of plagio. He has to go for skull x-rays first can anyone give me some insight on what to expect there? The Neuro- that we are going to has a team that does clinic once a week this team will assess my son and his x rays first and then if needed he will consult with the Head Neuro- does this sound right to you guys or should I be looking to consult with a Neuro Surgeon Directly first? DR Day who heads this team has been trained and certified with the DOC band-company so...... what are your thoughts? Thanks, Beck Dallas TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2001 Report Share Posted February 21, 2001 Beck, We did not have an x-ray, we had a 3-D CT scan. There are many people here who had the x-ray done and can better respond to you on what to expect with that. I think it would be a good idea to have the x-rays before the consult so they can rule out cranio before going on. I can't see that it would hurt to consult with the members of the team first to see what they say. If you are not comfortable with their explanation or diagnosis then pursue a meeting with the head guy. It could be that the team you refer to looks at plagio babies often and will be able to help you. Ultimately I would think it would be a good idea to consult with the head guy before making your final decision to pursue band/helmet treatment if you are in any way uncomfortable about the decision. Please let us know how the x-rays go!! Marci (Mom to ) Oklahoma Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2001 Report Share Posted February 21, 2001 From what I have read the 3-d Cat scan sounds more conclusive. I bet I will have to push to have that done. I am scheduled to have the x rays prior to the appointment and then will hand carry them to the appointment with me. Since is 2 months maybe I should do the x-rays and then once I hear the DR's recc. insist on the CT scan if they do not request one. I am not thrilled about having to put him through this or sedate it-but I suppose we should error on the side of caution. Thanks. Beck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2001 Report Share Posted February 21, 2001 Beck, My daughter had both an x-ray and a 3d cat scan. She was diagnosed with lamdoid craniosynostosis. Unfortunaetly, the x-ray could not give a conclusive diagnosis. With the x-ray, she was awake and my husband I had to hold her down and still (which was fun) while they took the x-ray. With the CT scan, she was sedated and had not after effects from that. She will actually be getting her DOC band next week as she still has residual plagio following her CVR for the lamdoid cranio. Make sure that the Neuro is 100% sure that it is just plagio and if you are not confident get a second opnion. HTH, Kathy mom to l lamdoid cranio CVR 1/18/01 DOC Band 2/26/01 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2001 Report Share Posted February 21, 2001 Beck, The best thing you have going is that you baby is so young. Do what your gut says is right. I just wish that I had pushed harder when was just 2 months old. Kathy mom to l lamdoid cranio CVR 1/18/01 DOC Band 2/26/01 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 11, 2002 Report Share Posted September 11, 2002 Your dosing sounds fine, you may want to experiment with higher doses of Peptizyde, especially if she starts eating larger meals. Sometimes improvements are more gradual, so you may see more benefits in the coming weeks. I personally don't believe these kids will have to take enzymes forever. But they are good for all to take just for the digestive benefits. Devin > I have my 7 yr old on peptizyde in the am before breakfast, at > lunch she gets a peptizyde and HN-ZYME prime and another > peptizyde and hn-zyme prime before dinner. I have noticed that in > the 2 weeks, she is a little cakmer,and uses words better,forms > sentences better. Her expressive language is still poor and she > has a processing problem. So, what can I expect to see? Am I > doing the enzymes properly? How long do we do the > enzymes(forever is ok)???????thanks Quote Link to comment Share on other sites More sharing options...
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