INSURANCE HELP

This section is devoted to helping parents with a Plagio child that have received a denial for Cranial Orthosis coverage by their insurance company. This section is still being developed and is currently incomplete. If you need assistance that is not offered here yet, please e-mail me at CAPPSORG@aol.com and I will do all I can to assist you. All of the reference links are in PDF format.  If you do not have a PDF reader, please go here: http://www.adobe.com/products/acrobat/readstep.html to download one for free.

We are in need of more Sample Letters. Where do our letters come from??  From wonderful families like you!!  If you have a successful appeal letter, would like to help fellow PlagioFamilies and will allow us to post your letter as a Sample Letter, please e-mail your letter to CAPPSORG@aol.com - All personal information will be edited out before the letter is made available to assist other families.

Before the Casting

• Pre-Authorization - A Pre-Authorization is needed by the majority if insurance companies BEFORE the casting process is done.  Most companies, Orthotists, and hospitals that offer Cranial Orthosis treatment know this and submit the Pre-Authorization immediately.  If the company, Orthotist, or hospital that you are dealing with does not submit a Pre-Authorization be sure to call your insurance company first, BEFORE the casting to be sure that one is not needed.  If a Pre-Authorization IS needed and one is not submitted, you could be waiving your rights for any coverage of your child's band/helmet. 

• Pre-Authorization Determination - Once the Pre-Authorization is submitted, you need to wait for the determination before starting the casting process.  It is rare that an insurance will allow for the Cranial Orthosis treatment to begin without this determination.  If an insurance company should say that the treatment can begin without the Pre-Authorization Determination, be sure to get this in writing.  With most insurance companies beginning treatment before this determination is made can result in waiving your rights to any possibility of coverage by the insurance company, including the appeals process.

• Where's Our Answer? - Unfortunately the waiting time can be long.  My insurance company took approximately 5 weeks before a determination was made.  Thankfully many insurance companies will make the determination quickly, however some of us are stuck watching the clock tick by.  If you find that your insurance company is taking a long time, call them a call every few days and ask for a status of the determination.  Get in contact with a supervisor, or with someone that is higher in command then a clerk, and make that person your contact.  Ask for their name and extension number and continue to politely ask for a status ever few days.   My "contact" eventually physically went and found out what was going on with our determination so that I would stop calling and because I asked him if he would help me.  But remember if you do this tactic, always be polite.  At this level, the person that you are dealing with has no control over how long the determination takes.  However, they may be able to assist you in getting the determination processed a little more quickly, or at least finding out what the hold up is, if they are inclined to help you - and they are usually only inclined if you are polite and they understand that this is a time sensitive treatment for your little baby.

• We Got Our Answer - 

  • Approval - If the Pre-Authorization was approved you can now begin the casting process and your insurance will pay the cost of the Cranial Orthosis.           

  • Denial - If your Pre-Authorization was not approved you can still proceed with the casting, however you will have to work out the payment details with the the band/helmet provider.  Most companies, Orthotists, and hospitals have payment plans, so be sure to ask about this.  While you are paying for the band/helmet you can continue to fight your insurance company in the appeals process.  Because it can several months to fight an insurance company, if you can afford it, being put on the payment plan if you have been denied is strongly recommended so you do not miss the treatment window.

The Appeal Process

When dealing with Insurance companies you have the right to appeal.  As far as we know, all states, insurance companies, and plan coverages allow for internal appeals.  An appeal is when you challenge a determination made by your insurance company in writing and supply information, documentation and evidence that supports your position.

Depending on what insurance company you have, and in what state you live, the process can differ.  Some insurance companies only allow for a set amount of written appeals and there is a deadline to begin each  (i.e., the appeal must be initiated within 30 days of receipt of the written denial).  Some insurance companies will hold a hearing to which you can attend to defend your position.  And in some states there is the option of external appeal (explained in greater detail later) that can be taken if your first appeal is denied.  For these reasons, it is important that you carefully review any information that is supplied to you about your particular rights to the appeal process.  If you are unsure or are not supplied information regarding appeals, call your insurance company and ask.

How Do I Write An Appeal?

The appeal letter that you write, must be specific to your denial.  In the past we have seen the majority of denials are based on "Plagio is cosmetic", "no functional impairment present", and "cranial Orthosis is not medically necessary". These denials tend to make up the greatest majority of what parents receive, however it is not uncommon to see other denials as well.

• Cosmetic, No Functional Impairment or Not Medically Necessary  - The cosmetic, no functional impairment or not medically necessary denials are all working off the same premise.  The insurance company is saying the Plagio is a cosmetic disorder and treating it would be akin to a cosmetic surgery, much like a nose job, and therefore, is not a covered benefit.  Of course we as parents know this is not true and thankfully so does the AMA. 

   

  • Resolution 119 Coverage of Children's Deformities, Disfigurement and Congenital Defects - The AMA clearly outlines the difference between "cosmetic" and "reconstructive" in Resolution 119 - click here to view resolution 119 - as you can see in this document it is clearly states that "Cosmetic surgery (treatment) is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem."  Whereas Reconstructive surgeries (treatments) can be "performed on abnormal structures to restore them to a more normal state."  This is a very strong point that many parents incorporate into their appeal letter.

  • AMA Policy H-185.967 Coverage of Children's Deformities, Disfigurement and Congenital Defects and AMA Policy H-475.922 Definitions of "Cosmetic" and "Reconstructive" Surgery- These statements are also found in Resolution 119. However, because some sample letters mention these policies, I felt it important to add them so that you can view the policies for yourself (just click the policy numbers following this paragraph). It looks as though these policy may be a current, separated versions of Res 119, as the date on the AMA website is for both policies is in July of 2003. I am currently in the process of finding out what exactly H-185.967 is and once I find out, I will make the appropriate changes to this page. H-185.967   H-475.922

   

  • Alternatives vs. Cost - Another point that many parents like to outline the other possibilities for treatment.  Basically the options that we parents have is to A) Do nothing now and subject our children to surgery later in life if the Plagio does not correct, or, B) Use a Cranial Orthosis now to prevent the further need for any other treatments in the future.  Obviously using a Cranial Orthosis now is much more non-invasive and is far less expensive then resorting to a surgical solution later in life.  In fact in the article "Abnormal Head Shapes in Infants" by Deirdre Marshall, MD., that was published in the International Pediatrics The Journal of Miami Children's Hospital Volume 12 Number 3, 1997 states "at four of five months of age, if there is still a significant flattening on one or both sides of the occiput , helmet therapy should be instituted.  Insurance companies and Health Maintenance Organizations must realize that prompt authorization  of requests for helmet therapy in children requiring them will, in the long run, be much more cost-effective then denying or postponing authorization for a helmet and then having to fund a major intercranial surgical procedure."

   

  • Spontaneous Correction Will Not Occur - A very strong quote from Importance of Early Recognition and Treatment of Deformational Plagiocpehaly with Orthotic Cranioplasty Kelly KM, Littlefield TR, Pomatto JK, Ripley CE, Beals SP, and Joganic EF; Cleft Palate Craniofac J. 1999; 36: 127-30 to support Band/Helmet therapy is "Unfortunately, clinical experience, and anthropometry data that for many of these untreated children, the anticipated spontaneous will not occur.  For this reason, early recognition and treatment of Plagiocephaly are essential to obtaining the optimum clinical outcome."

   

  • Sample Letters - Here are some sample letters that have been successful in fighting either the cosmetic, no functional impairment or not medically necessary arguments:

     

    • Sample Letter 1

    • Sample Letter 2

    • Sample Letter 3

    • Sample Letter 4

    • Sample Letter 5

    • Sample Letter 6

    • Sample Letter 7

     

• Investigational/Experimental - Recently insurance companies have begun to challenge that Cranial Orthosis treatment is investigational/experimental.  If your child's helmet/band is FDA approved, this argument is much easier to fight.  You can find all the FDA regulation information of the DOC Band on the Cranial Tech Website in the "library" http://www.cranialtech.com/ParentsArea/researchArticles.html. FDA regulatory information for other FDA approved helmets/bands can be found at the FDA website http://www.fda.gov/cdrh/index.html by doing a search of the name of the Band/helmet or the company that manufactures it.

   

  • Sample Letter - Here is a wonderful sample letter that was successful in fighting the Investigational/experimental argument made against the DOC Band.  Although this letter was ultimately used for a grievance hearing, it will serve as a wonderful template for written internal appeals as well:

    • Sample Letter 8

  • Sample Letter - Here is another wonderful sample letter that was successful in fighting the Investigational/experimental argument made against the DOC Band. In addition, there is also a copy of the cover letter that was attached to the carbon copies (Cc's) for this letter. In this situation, the carbon copy letters resulted in assistance from a local Congressman as well as the Maryland State Attorney General's Office and the Maryland State Insurance Commissioner's office, which greatly helped in the insurance company overturning their original denial.

    • Sample Letter 9

      • Carbon Copy Cover Letter

       

• Orthotic Exclusions - The Orthotic exclusion denial is a bit trickier for us to discuss because there are no real articles and such that we can supply to counter this denial. Most of the information that you will need to explore is in your insurance policy. If you do not have a copy of your insurance policy request one from your insurance company, or through the human resource department with whom the insurance company was obtained. Look for their definition of Orthotic and what exactly their policy is. Also finding out if others have been covered for the same treatment by your insurance company can help as well. If your insurance company has paid for the same services for other families after the date that the orthotics exclusion was put in place, it could be helpful to point this out to the insurance company and demand equal treatment as it must be some form of discrimination against your child.

• Sample Letter - Here is a wonderful sample letter that was successful in fighting an Orthotics exclusion. As you will see reading and understanding your policy while also understanding the AMA policies is very important. You will find resolution 119 and AMA Policy H-185.967, mentioned in this letter, in PDF format above.

• Sample Letter 10

• Sample Letter - This sample letter is truly a wonderful letter! Not only does it fight the Orthotics exclusion argument (one of the hardest arguments to fight), but it is also against Tricare Humana, which I know from talking to many families has always been one of the more difficult insurance companies.

  • Sample Letter 11

   

• Denial Due to Failure to Prove Conventional Therapy (repositioning) Prior to Helmet - This was a new denial for me. Never before had I seen an insurance company deny on the grounds of insufficient proof of repositioning for a long enough time frame prior to moving onto helmet treatment. I believe that the Sample Letter covers everything for this specific denial.

  • Sample Letter - This is probably my favorite sample letter. I honestly believe this denial reason to be the most ridiculous yet and truly and example of an insurance company scrambling to find any reason to not pay. The mom that wrote this sample letter did a splendid job pointing out that how could the insurance company possibly know what "conventional" therapies were done and for how long, when they were done by herself and her husband in the privacy of their own home!

    • Sample Letter 12

As more denial reasons become known to us, and as more sample letters are collected, we will add to this section. (Please send us your successful appeal letters so we can continue helping PlagioFamilies with insurance denials)

Due to a large number of requests, here is a copy of my external review from the NY Board of Insurance that overturned UHC's decision to not pay for my daughter's DOC Band due to the reason of  "no functional impairment". Unfortunately I have not been able to find time to write a section on External Review, but I hope that this letter will be helpful to fellow NY'ers who are appealing and to anyone fighting the "no functional impairment/cosmetic" argument. Sample Letter If anyone has an external appeal letter that they would like to share, to help other PlagioFamilies, please send it to CAPPSORG@aol.com

I WROTE MY APPEAL, NOW WHAT?

Your letter is complete and now it is time to send it.  Here are some suggestions of things to do before you send your letter.

• Check For Press Releases - This tip was given to us by a mom who after checking press releases from the State Medical Association discovered that her insurance company was in the process of being sued by the State Medical Association for delays in payment as well as for denying medically necessary care, amongst other things. If you should find something to this affect, it could give your appeal a little more weight by mentioning it in your appeal and also CC a copy of your appeal to the Medical Association.

• Cc Your Letter -  When fighting an insurance company it doesn't hurt to try and gain support from others.  Many families, including myself, Cc  and send their appeal letters (with the addition of a cover letter explaining why they are sending the person the appeal letter) to every government official they can think of.....their senator, their congressman, their insurance commissioner, etc......although this may not bear fruit, we have heard of a case where it was believed that a government official did become involved to the benefit of several PlagioFamilies, so it is always possible that this could happen again.  Another recipient of your appeal letter to consider would be your local media.  We have heard of cases where families have won appeals and believed it was the Insurance company's solution to diverting bad publicity. Although Cc'ing your letter may result in no additional help, it is a way to make others in positions of authority aware of the insurance struggles we PlagioFamilies face. Perhaps if enough letters are received by these individuals, they will eventually do something about it.

• Making Sure Your Letter IS Received - When you send your letter, as a bare minimum, be sure to send your letter with Return Receipt and Tracking (and retain that tracking number!).  It is not uncommon for insurance companies to say "Sorry, we never received your appeal letter", so it is very important that you have some type of record to prove that you did indeed send it and that it was indeed received. My insurance company tried to pull this on me, saying I missed our appeal deadline because nothing was ever received, but fortunately I had the tracking number of the sent letter.  I gave the tracking number to the insurance company, they verified that the letter was indeed received, and then it was on them to scramble to find it -- which they eventually did. Had I not had proof, the outcome of that scenario would have been much different and to the insurance company's benefit.

Special Thanks to all the parents who have sent us successful appeal letters to use as samples! This page would not have been possible without your help!

CAPPS is a non-profit organization run by only PlagioParent/CranioParent volunteers, all money donated goes right into helping us continue our awareness and education projects, as well as keeping this website up and running to help other families. If this page has been helpful to you in winning your appeal, please consider sending CAPPS a small donation - every dollar CAPPS receives goes a LONG way and makes everything we do possible. To read more about how to help CAPPS please visit our Support CAPPS page

Please note this section is not complete - additional information will be added as I find the time.  If I have stopped in a section that you are in need of information for, or have not yet covered a topic you need assistance with, please feel free to e-mail me at CAPPSORG@aol.com and I will do my best to assist you.

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©Craniosynostosis And Positional Plagiocephaly Support, Inc.2001