I don’t think I’m alone in my thinking that sometimes insurance companies can be difficult to deal with. Sort of like cable/internet companies. We’ve all dealt with the internet company games, haven’t we? I’ve had my fair share of those long conversations just to save $10/month or something ridiculous. This sort of feels like the same thing- only worse!
At our son’s 4 month appointment his doctor suggested we go see someone about his head as he appeared to have a “misshaped head.” It wasn’t the best thing to hear because we have been working on tummy time everyday from about 10 days old. We have my sister to thank for that but sometimes things happen. I’m still convinced it was due to his wedged spot in my rib cage for 1/2 my pregnancy.
We had trouble getting in to the technician and were under the wire because our insurance company would be changin July 1st and our deductible and out of pocket maximum would be significantly increasing. After a few back and forths with changing appointments I grew frustrated and decided to make an appointment to see a speicalist a the Children’s Hospital. After an evaluation and some x-rays to rule out premature closing of the plates of the skull we were sent back to the original technician in town to order the helmet.
We experienced the literal runaround with the insurance company which was exhausting, frustrating and heartbreaking at times. July 1st we changed insurance companies and we were literally 3 weeks before this point when we made that first appoitnemnt. They are unable to bill the insurance until the helmet is delivered, add on the time before this for the pre-authorization which our old insurance company told me would be ok’d as it was included. But we couldn’t chance it and have it delivered July 2nd and insurance company 2 deny it becuase it wasn’t pre-authorized. So I called our soon to be insurance company and they told me they couldn’t tell me the cost of the helmet it is something covered in the plan. Phew, a sigh of relief. So fast forward to July 1, I call the insurance company to find out what we need to do to start this process and to make sure the provider was in the network. The woman informed me no, it was excluded from our plan. After I kind of lost it, I took the information down and decided I’d try to call back again later. Answer number 3 of whether or not this was covered came later that day when I was told there were exclusions but could be covered if certain criteria were met- one of which was physical therapy.
His PA at Children’s ordered PT after my request- and hoping this would help with the insurance company. After finding out that no it would not be covered I asked the PA to challenge the decision. Much to my surprise, as I was thinking it would never get reversed, I received a call saying they reversed the decision!!!! I cannot convey the headaches and stomachaches this caused us.
I think I spent over 7 hours on the phone about this one issue in 2.5 weeks! I will say that some higher up from the insurance company did call me to tell me about the reversed decision and to appologize for all of the issues we had and things they were doing to correct it so others do not have to go through what we did.
You want to do the right thing as a parent for your child and how can you put a price tag on something he needs? I knew we would get the helmet either way because I didn’t want him growing up and asking why we didn’t fix it or something to that effect.
The moral of my story is to not give up hope. Next time we might not be so lucky. I don’t know why they changed their mind- maybe enough people heard about this situation becuase I went to my employer’s HR department looking for someone else to contact, 7-10 phone calls to the insurance and many other people. At one point I had three different people “working on finding answers” for me! If you’re going through the same thing, hang in there! Just in case you aren’t able to get the insurance company to pay for it, there are grants available- check out United Healthcare Children’s Foundation!
I’ve had quite a few people mention to me that they used to let babies sleepy on their stomachs and then they didn’t have to worry about flat head issues and how it seems many babies nowadays needs a helmet. I found this from the American Academy of Pediatrics Clinical Report and found it helpful.
The incidence of positional skull deformity has been estimated to be as low as 1 in 300 live births to as high as 48% of typical healthy infants younger than 1 year, depending on the sensitivity of the criteria used to make the diagnosis.14 Since the American Academy of Pediatrics Task Force on Infant Positioning and Sudden Infant Death Syndrome (SIDS) in 1992 recommended that healthy infants be positioned supine for sleeping, the incidence of SIDS has decreased from 1.2 per 1000 live births in 1992 to 0.56 per 1000 live births in 2001.3,6,15 Coincident with this decrease in SIDS has been a drastic increase in positional skull deformity, estimated at approximately 13% in healthy singleton infants,14,15 which makes this a relatively common issue to be faced by the pediatrician caring for infants and their families.
You can find the entire report here: https://pediatrics.aappublications.org/content/128/6/1236.