Appealing Insurance Denial of Helmet

Having written numerous letters for appealing insurance decisions (and luckily have only lost one), I have found that it is important to include any other treatment or therapeutic measures that you have tried that have not worked, make sure that the Dr. or PT person includes the deviation from normal that the asymmetry is, the projected benefits of using the helmet instead of continuing with other methods, and if there are any potential cost savings benefits to getting the helmet.

My SIL/BIL twins needed helmets due to prenatal positioning, but their insurance did consider it to be "cosmetic" so they helmets were denied and they had to pay for them themselves (but did max out flex dollars that year so that helped).

Good luck!

http://www.babyflathead.org/what-to-do-if-your-helmet-ins...

There's a limit on the amount of appeals so get some info first. First you need to find out exactly what the denial says and why they denied the service. Is it something your policy covers? Was the letter just a predetermination of benefits meaning they send in what they wanted to do and asked the insurance how much would be covered?

Personally I'd probably go see the plastic surgeon and have him do the request (if its covered under your plan). He would be able to address more of the medical issues that the insurance company would need to know about. Also information from the PT would be good to point out specific developmental concerns

talk to the dr. see if they know any ways to get the ins. to pay for it.

I have not heard of one being covered because insurance considering them cosmetic. I wonder if you could pay out of pocket (not sure if this is in your budget).

Some deny it because they call it cosmetic, I would continue to appeal but since time is an issue I would consider getting it and paying out of pocket and then trying to recoup that amount rather then margin the child wait.