Before you take the plunge in dealing with your Insurance Company, look over your policy one more time, and then take a few minutes to look over these questions and answers. If you have a question that isn’t represented here please feel free to write Kali at tnt@isoc.net and I will try to answer your question, and will also post it here, as well, to help other parents.

These questions and answers are intended to give you a way to help you in your interactions with your insurance company and are not meant to be a substitute for information that may be better provided by your State Insurance Company  

  My child is over 8 months old, and I really don’t want to put this off any longer than I have to.  My Insurance Company hasn’t given me an answer yet on if molding treatment is covered.  Should I start treatment without a definite answer from my Insurance company?

As hard as it is, please WAIT.  If they happen to tell you to “Go ahead and start the procedure while we process your information.” GET IT IN WRITING.  Do not do anything from a verbal confirmation, even if you get the representative’s name and extension number.  If the Insurance Company happens to deny you coverage because you “did not follow the proper steps” (wait for approval, etc.), this is one of the hardest denials to appeal. The day you get your verbal denial, you can schedule your casting for your molding device, as long as you are sure that they are sending you a written denial as well. Try not to take anything verbal as confirmed, even if it is in your favor. Ask:  “When can I can expect to receive the written documentation for the information you just told me?”

  My Insurance Company has told me that they will not cover treatment for plagiocephaly because they feel it is only for cosmetic reasons.  I’m concerned about the possible long-term effects of plagiocephaly for my child.  How do I get them to recognize that this isn’t a cosmetic issue?

Each case will be different.  Depending on the severity of the plagiocephaly, and when it began, the insurance company may accept some cases, and deny others (sometimes of the same “circumstance” and “type”).  Not many insurance companies will automatically accept your claim.  In order to successfully appeal, you need to objectively collect information that will help prove your case. 

• Birth documentation (was your child constrained in-utero (big baby, breech baby, multiple birth); was vacuum extraction or were forceps used during birth; did your child have torticollis from birth; was your child premature or in neo-natal care for any length of time?)  A Letter of Medical Necessity from your doctor or specialist can help this case, as well as information from your child’s hospital and pediatrician records if necessary.
• Other treatment documentation, such as diagnosis for torticollis and therapies prescribed for resolving this.  If the doctor told you to use repositioning to resolve the flat head, take pictures of the multiple ways you used repositioning throughout the day, during the waiting period, with a camera that shows the date, if possible.  Consider submitting photo documentation of the head asymmetry and other associated problems, or of therapy sessions with the physical therapist. Also consider submitting measurements of asymmetry if you have someone to take these.  If you or your doctor submits this information, consider comparing this to a typically “normal” head measurement.
• Be familiar with the AMA resolution document (found in the files section of the Plagio parents support group http://groups.yahoo.com/group/Plagiocephaly) which states in part:

 “Cosmetic surgery [therapy] is performed to reshape normal structures of the body… Reconstructive surgery [therapy] performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, etc.…is generally performed to improve function, but may also be done to approximate a normal appearance.” [emphasis and brackets mine].  Find out what other types of reconstructive therapy that the Insurance Company covers (such as breast reconstruction after breast surgery), and if necessary use these examples in your appeal.

• Detail the major issues you are concerned about – and try to find documentation that confirms your concerns.  For example, possible long term problems if there is facial asymmetry can be TMJ or other jaw problems, increased ear infections, possible eye problems, etc.  Speak to your doctor, and try to get information/documentation that supports your concerns. (Insurance companies like to be seen as “pro-active” to avoid other long-term problems or effects with clients, but often you have to remind them about their commitment to avoiding long-term problems or effects.)
• See answer below in helping to formulate your documentation.

  I sent in over 30 pages of information giving/showing my Insurance Company the documentation they said they needed, and they still denied me!  How can this be?!

In the Insurance Company’s mind, just because you send documentation, articles, etc., doesn’t necessarily means that this information is pertinent to your case.  Even when doctors send letters of medical necessity, treatment isn’t always accepted the first time around, much to the frustration to many a parent. In many cases, it is the Insurance Company’s position that you have to prove the need and necessity of this treatment to them.  How?  By being logical, knowledgeable, and consistently refuting their reasons for denial. 

Try to see the denial as a positive thing – something concrete that you can now attack with a definite plan. 

Overwhelmed?  Frustrated?  Please don’t be. Just take it one step at a time. 

One way to organize your thoughts is to take your initial denial letter, and on a piece of paper write down each reason for denial, leaving a bit of space under each reason.  Then, starting with your letter of medical necessity (if you were given one), and working your way up to any documentation you may have acquired about plagiocephaly, or treatments, etc., find pertinent quotes within the articles that logically REFUTE the denial statements, and write them down under the different reasons for denial. If you are short of information, there are some wonderful letters on the Parent’s Plagio site (http://groups.yahoo.com/group/Plagiocephaly) in the files section under “Insurance Help” to help you out.  There are also articles there, as well.

 It might take some time to do this. Then use any information you gather to help you craft your appeals letter.  Your appeals letter will be much stronger if you include these quotes within the letter rather than just sending the Insurance company a bunch of articles that they may or may not read.  Referencing the articles with actual quotations shows them that you have done your homework, that you know about this condition, and the different ways to treat it, and that you expect that your claim be seen as valid.  It is harder to blow you off when you show you know what you are talking about.  Try not to make your whole letter a quotation – give valid and real examples for your reasons for using the quotes.

Be sure to show knowledge about the Insurance Company, as well.  If they send out videos or other information (such as exercises for back pain), or support alternative therapies such as massage and meditation, be sure to let them know that you know this and you are “shocked” at their decision not to treat your child’s condition, which has been linked to other long-term effects.

Also document any quote you take from articles, etc., and be sure to include any article, etc. that you quote from in your appeals packet.  Be aware that all insurance policies are different, and there may be some insurance companies that just will not recognize plagiocephaly treatment as a covered claim. However, even understanding this, please don’t give up after the first denial, or even after the second, if it comes to that… use the number of appeals allotted to you, and contact your State Insurance Department  if you feel that your Insurance Company is not handling your claim correctly.

  I’ve heard that once an Insurance company has denied you for one reason that they can’t suddenly change reasons on you and tell you they are denying for something else. Is this true?

Check with your State Insurance Department   for your state rules regarding this, as they may vary.  For Home Insurance and Car Insurance this is the standard, and most probably this is the case for most states and Health Insurance Coverage, but please verify by your state department.

What does it mean to “change reasons?”   For example: If your insurance company denies your child for treatment by saying the molding device is “experimental” and that is the only reason that they give you -- and you send convincing evidence that it is not, then their next correspondence to you should not be “While you’ve shown that this is not an experimental procedure, we deem this treatment as cosmetic.”  That is changing the reason for denial. In this case, contact your State Insurance Department to see if this is a valid procedure for your Insurance Company to follow. Inform your Insurance Company that you are investigating the validity of them changing the denial status with the State Insurance Department.  90% of consumers do not question the decisions of their Insurance Company.  When you deal with them, let them see that you are knowledgeable about what you are trying to get approval for, and that you are ready to fight for this.

Often Insurance Companies will give multiple reasons for denial in the initial denial letter in order to avoid being proven wrong for one reason.  If this is the case, be sure to address each denial reason in your appeals letter with logical argument and pertinent documentation.

  The Insurance Company has “lost” my appeals packet (they say it never arrived), and now I only have one day left before my appeals limitation is up.  What can I do?

Call your State Insurance Department and find out your rights.  Unfortunately, in this case, it is hearsay on whether they received your appeals or not. Always send things in the mail with a tracking/confirmation number (usually it’s less than 50 cents to do this).  Or, if you want to be extra sure, send things certified mail.  As well, always make multiple copies, and on your letter, include all the people that you are sending the appeals to (for example, to Ms. ****,  Insurance Director,    and at the end of the letter,  cc: Dr. **** (neurosurgeon), Dr. ***** (pediatrician), etc.  If you sent all these letters at the same time, and the other recipients received the dated packets, you can at least prove that the packets were sent out in ample time of the deadline.  If you made multiple copies and kept a few for yourself, using an overnight mail delivery to meet their arbitrary deadline shouldn’t be a problem, but still consider contacting your State Insurance Department. Don’t hesitate to let your Insurance Company Customer Service Representative know that you are doing this since you know you sent the packet on _________date.  You might suddenly get an “extension.”

  Every time I speak to the Insurance Company I get tongue tied.  I get tired telling our case over and over again. Why can’t I speak to the same person each time I call in?

All Insurance Companies are different.  I happened to get some pretty impressive “run-around” behavior when I was trying to find out the status of our appeals, including getting cut-off when I was on hold several times.  Some suggestions:

Dealing with Customer Service Representatives:

1. Be calm. Be knowledgeable.  Be persistent.  Talk with a smile, if at all possible. But when necessary, be Firm, and ask for a supervisor.

2. Know what it is you are calling for.  Have all possible information ready to give. Keep a written information handy that explains why you are calling, and what information you are looking for so you don’t forget to mention anything.

3. Keep track of every phone conversation. Date, time, how long on hold, etc.  Ask for phone extensions, names, and department.  If you find that when you call back a day or two later and the person you talked to suddenly doesn’t have the extension you were given, or there is nobody in that department with that name – RECORD this and keep it for ammunition if you need it. Also keep track at the number of times you are “inadvertently cut off,” if necessary.  Hopefully this information will never be needed, and you will be satisfied with the customer service.

4. Get it in writing.  From day one.  If accessible, ask for a fax of the information that they verbally tell you.  If this is not an option for you, ask for the information to be sent to you via e-mail or regular mail.  Whatever the first customer service representative tells you, even if it is “Yes, your plan covers this treatment” – ask for documentation and confirmation.  If they tell you to check your policy, tell him/her that it is their job interpret the policy, and if they cannot, to please connect you to someone who can. 

5. If you find yourself in a continuous loop where you don’t seem to be getting the information you need, or you get conflicting information every time that you talk to a customer service representative, politely ask for a print-out or screen print of the information that they are looking at on their computer screen.  They will probably resist, but it is your right to have documentation, and they have the responsibility to give it to you – though they may not be legally bound to give you your files (check with your State Insurance Department).  Just asking may shake them up a little.  Before you do this, you might want to detail to the representative you are talking to what you have been told in the last few phone conversations (which you can easily do since you’ve kept track of the calls…).

6. Don’t be afraid to ask for a manger – or supervisor – of the department. Or to take a drive up to the office you are calling, and make a personal visit to speak to the manager (something I didn’t have to do, but only because they finally resolved my issue the day I was going to do so).  If you have a hard time trying to get anyone to give you the information you need, try not to be extremely negative/angry – but do let them know you are NOT pleased with the treatment you have been receiving and that you are contacting your State Insurance Department.

7. Consider doing some of your correspondence by FAX and certified letter, but be aware that some insurance companies might even consider a letter of questions an “appeals” letter, and take this off of your allotted number of appeals.  Also be aware of deadline dates to file appeals.

  Our Insurance Company says that using a molding device is “experimental” and therefore will not cover it. What can I do?

First of all, ask for detailed explanations of their criteria, and what it means to them to be experimental.  Then detail what it takes to become approved through the FDA and how long it took before your company became approved (which usually 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”).  Tell them that you are contacting your State Insurance Department if they do that. Also, molding devices have been around since the 70s, so this type of treatment is not “new.”

  Why does my Insurance Company cover a molding device under Durable Medical Equipment?  It can’t be used again like a wheelchair or crutches.

The Durable Medical Equipment (DME) label is a confusing one at best.  Some Insurance Companies use this category for accepting a claim for a molding device, others might reject for the same reason. READ your policy, get interpretations from the customer service representatives (in writing if possible), and see what the company will cover and try to use the label you need to get the device covered.

A special thanks to Kali for all of your help on this page!!

THANK YOU!