Cleft Advocate - Helmet Therapy (Plagiocephaly) Appeal Letter

XXXXXXX XXXXXX

XXXX XXXXXX XXXXX

XXX XXXXX, XX XXXXX

(XXX) XXX-XXXX

March 4, 2005

Insurance Co. Name

Address

City, State, Zip

Re: Patient:

Id#:

Group:

Group #:

Record#:

To Whom It May Concern:

Please accept this letter as XXXXXXXXXX XXXXXXX’s appeal to (Insurance Co. Name) decision to deny coverage for DOC Band treatment. It is my understanding that coverage for DOC Band treatment has been denied, based on your decision that the care “…is considered cosmetic and is not eligible for benefits under the plan.”

The AMA has determined conditions like plagiocephaly are reconstructive, not cosmetic and therefore should be treated. H-475.992 Definitions of “Cosmetic” and “Reconstructive” Surgery. (1) Our AMA supports the following definitions of “cosmetic” and “reconstructive” surgery: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. H-185.967 Coverage of Children’s Deformities, Disfigurement and Congenital Defects. The AMA declares: (1) that treatment of a minor child’s congenital or developmental deformity or disorder due to trauma or malignant disease should be covered by all insurers; (2) that such coverage shall include treatment, which, in the opinion of the treating physician, is medically necessary to return the patient to a more normal appearance (even if the procedure does not materially affect the function of the body part being treated);

XXXXXXXXXX is a twin who was laying transverse in-utero and her twin brother was breech. She was delivered by emergency cesarean section on June 23, 2004 and she was twin A. Her birth weight was five pounds, two ounces and her twin’s weight was six pounds, ten ounces. She and her brother were both in the NICU for a period of time after birth. Within the very early weeks of her life, there was a noticeable flattening of the back of her head. Her pediatrician recommended a rigorous campaign of repositioning her frequently during the day and night. We diligently did this until Jacqueline was six months old. At this time, her pediatrician recognized that acceptable and appropriate treatment was cranial orthosis since repositioning was not having any effect. Another by-product of this developmental abnormality is the development of torticollis. As she turns her head from side to side, she cannot get a full range of motion without turning her shoulders in conjunction with her head. This in turn, has had the misfortune of us having to do a variety of neck stretch exercises with her five times a day in an attempt to help her develop an appropriate range of motion so when she is addressed by name, she can turn her head to the side without having to turn her whole body.

We have provided for XXXXXXXXXX the appropriate and recommended interventions to try and change what was happening. Our seeking medical intervention is by no means a cosmetic solution for XXXXXXXXXX; rather we are concerned about the medical problems that could result from non-treatment of this condition. An article in Pediatrics titled, “Diagnosis and management of posterior plagiocephaly.” By Pollack, IF, Losken W, Frasick P., 1997; 99:180-185. states, “Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone; 34 patients failed to improve and were treated with molding helmets.” The denial letter to us stated; “no objective documentation of a functional impairment that would be improved or removed by cranial remolding orthosis.” I will argue that it is an ethical violation to carry out such studies because parents are NOT willing to take part in studies that leave their child untreated. It is at the professional recommendation of Jacqueline’s pediatrician, Dr. (dr.’s name), and Dr. (dr.’s name) at the Institute of Reconstructive Plastic Surgery at NYU Medical Center that we seek this treatment.

At this time, we feel it imperative that (Insurance Co. name) provides us with a complex care caseworker. It would be of benefit to both the company and us as there would be one central point of reference and hopefully, an adequate resource of accurate and updated information.

It is important to note that helmet therapy for this condition can only be done within a short time span. Once the bones of the skull fuse, there is no treatment other than surgery to correct this. A small amount of money released for care during the time when things are still pliable and malleable will surely save on costly surgical procedures and lengthy hospital and rehabilitative services in the future. SP Najarian says, “If the flat spot is moderate to severe, use of a molding helmet should be considered. The window of opportunity to act when the cranium is less calcified and growth is at a maximum, must be taken into consideration.” (J Pediatric Health Care 1999; 13:173-177.)

Your denial did not give adequate information about this decision. Please provide the following information to support the denial of benefits for this treatment:

1. Please furnish the name and credentials of the insurance representative who reviewed the treatment records.

2. Please provide an outline of the specific records reviewed and a description of the records which would be necessary in order to approve this treatment.

3. Please provide copies of all expert medical opinions which have been secured by your company regarding plagiocephaly and/or DOC Band treatment, in order that the treating physician may respond.

So you may further review this case, I have enclosed photographs of my daughter so you can see why this treatment is necessary. Also enclosed are the measurements of her head and a chart showing Cephalic Index Norms. Upon review, it will be apparent that XXXXXXXXXX is not in the range of normal and she needs this treatment to improve the range of motion in her neck and approximate a normal appearance. I have included a copy of the letter of medical necessity written by her pediatrician and a copy of the original prescription from the Institute of Reconstructive Plastic Surgery. Also included is a brief article from the Plagiocephaly website regarding this condition.

Thank you for your assistance.

Sincerely,

Mrs. XXXXXXX XXXXXXX

Address

City, State, Zip

Phone Number

Encl.

cc: Dr. ________________

Dr. ________________

Insurance Broker Name

Cranial Technologies

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