Re: CIGNA 1st level appeal denial

[Guest guest]

Dawn:

I understand your frustration. Cranial Technologies has documents (that you very well probably sent to CIGNA in your first appeals packet), that shows a CT scan of a baby's head, and an older head with the same deviations -- showing that after a certain age, correction did not occur in that case, and there is information out in other article that points out that there are higher incidences of TMJ, ear infections, as well as other problems depending on the severity of the plagiocephaly. You could always play "hard ball" and ask them to guarantee to you that these problem will not occur if you do not correct your child's head....or something such as the "I was very surprised" sentence in the paragraph below....

We had CIGNA, and did win -- but I had a three page appeals letter, as well as five pages of pictures... and documentation. I "shamed" them in my first level appeal with this paragraph:

"I received a copy of your letter dated May 15th, 2000 in which you state that our request for a DOC® Band has been reviewed by Dr. xxxxxxxxx, Medical Director at CIGNA Healthcare. This letter stated in part that our request had been denied “due to lack of conservative measures like Postural Therapies, and the abcense [sic] of Craniostosis [sic] [craniosynostosis] or any other Neurological abnormalities.” I was very surprised by your decision, especially coming from an insurance company that takes great strides to encourage its clients to take measures to avoid catastrophic medical illnesses by promoting regular exams and educating clients through healthy lifestyle bulletins as well as videotapes and other timely and pertinent information. "

The statement you received is a new one to me -- though I've seen some companies deny because of "experimental nature" of DOC and other devices...However, the DOC band is an FDA Approved device and had to "prove" itself to the FDA through research articles and other data. Find some definitions of "experimental" and then detail what it takes to become approved through the FDA and how long it took before CT became approved (which includes success rate). Once you LOGICALLY dispute their denial, it becomes harder for them to uphold it (though some companies will, because they are tenacious and try to wear you down). Once they deny you for one reason, they aren't supposed to come up with another reason ( for example, them saying to you "ok, so you've proven it's not experimental, but we see it as a cosmetic issue").

Also , helmets have been around since the 70s so skull remolding is not "new." In my letter I referenced the Craniosynostosis and Head Molding Symposium (which was quoted from a CT article) that stated:

Cranial banding therapy is most beneficial before the 1st year, and the guidelines established at the 1997 Craniosynostosis and Skull Molding Symposium state in part that “If repositioning is unsuccessful, or if the initial deformity is too severe, or if the child is too old for repositioning to be effective (5-6 months) Orthotic Management should be considered at the next logical alternative.”

So, there is research out there that can help you in your second level appeals, though you might have to do a little digging through the research articles and pull out specific quotes of specific research to help prove your point.

There are a couple of CIGNA appeals letters in the files section under Insurance help that were approved. Now that you have a denial in writing, all you need to do is to logically refute what they say (or your doctors do, or your CT technician, or all of you) with as much specific/quoted material as possible.

Hope this helps a little.

Good Luck.

H.

Mom to Quinn

-----Original Message-----From: ripmble@... [mailto:ripmble@...]Sent: Friday, March 02, 2001 3:26 PMPlagiocephaly Subject: CIGNA 1st level appeal denialWe just received our first level appeal denial. The preapproval was denied because "the reason for the band appears to be cosmetic". I sent them an inch thick packet of data. This letter doesn't even bring up "cosmetic" and "medically necessary" but says that cranial bands for PWS (plagio without synostosis)have been reviewed by the Technical Evaluation Center and do not meet four of their five criteria. It meets the FDA approval, but says "without any direct comparative data from well-designed studies on the health outcome effects of cranial orthosis in comparison to active positioning intervention or no intervention, the evidence is considered insufficient to permit conclusions on this technology". So they don't have enough untreated, malformed babies to study into adulthood and see how messed up they really are.Getting this letter and then seeing the article in the Arizona Republic about CIGNA paying for massages just makes me crazy!Anyone else get this "new technology not proven" denial? Any suggestions. I've asked our specialist and CT to write responses and have scheduled a second level appeal.I'd always heard they can't give you a different reason for a denial the second time but evidently they do.Dawn R.Ft. Laud FL Mom to

[Guest guest]

Hello Dawn, we also have the same ins. I'm trying a new approach and If it

works I will let you know.

[Guest guest]

Dawn,

I am having the EXACT same problem. Told me it was cosmetic throughout the

entire appeals process then when they sent me the FINAL denial letter they

added the not FDA approved garbage...grrrrr. I also was of the understanding

that they couldn't do that. I would suggest a filing a complaint with your

state dept of insurance if you have a PPO or with your state dept of health

if you have an HMO.

Marci (Mom to )

Oklahoma