Maysa's Blog

Our journey through plagiocephaly and brachycephaly

Posts Tagged ‘referral letter’

Kaiser approved our second DOC band. Hooray!

Posted by mymaysa on January 13, 2009

I am so happy; I can’t find the words to express myself! Kaiser Permanente is now covering our second DOC band in full after initially sending us a denial letter in the mail.

Here is the story:

On December 31st, Kaiser sends a denial letter for a second DOC band stating that “insufficient clinical information has been provided to determine if the requested service is medically indicated. Current clinical information that documents Maysa’s history, examination findings including the current measurements pertinent to establishing the medical necessity of DOC banding that reflects the extent of her response to prior treatment, is required in order to establish whether the requested service is a covered benefit and medically necessary. Therefore, A Durable Medical Equipment (DME) item, DOC banding/cranial remolding banding, from Cranial Technologies, Inc., is not a covered medical benefit, at this time.”

The letter also gave the name of the doctor who denied the claim, Dr. Gregory Alexander, his phone number and address.

Another paragraph also states that our pediatrician could call a number to discuss our case and request a reconsideration on our behalf.

First things first, I try to call Dr. Alexander and leave two messages on his voicemail but I never hear back from him. The third time I call, I get him on the line. He explains to me that the reason why he denied the claim is because he couldn’t read the numbers that CT faxed him. He also said that he asked for new copies but that he never heard back from them. I then contact Sandra Vatalaro. She tells me that Kaiser never tried to contact them. She then emails me all the paperwork she faxed them. I print them out and fax them to Dr. Alexander along with the scans of Maysa from Orthomerica. I attach to that a letter explaining things a bit further.
I also contact my pediatrician via email and ask if she would request a reconsideration on our behalf. I also fax her all the documents I faxed Dr. Alexander and then I wait. The letter said that I should receive an answer within 10 days of submitting the request.

Today, 01/13/2009, I get a call from Tammy, Dr. Alexander’s assistant, with the news that after reviewing the documents I faxed them, that the doctor has approved a second DOC band for Maysa.

I am just so so happy, so happy for my Maysa!

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