Insurance Claims


Many insurance companies still designate the treatment of vascular lesions
as cosmetic surgery. The difficulties of collecting from insurance companies
for treatment may make some doctors hesitant about becoming involved in
the treatment of a vascular lesion.

There is a growing movement of parents across the country who have been working
to persuade insurance companies to change their policy regarding coverage
for the treatment of vascular lesions. Also, doctors are asking organizations
that support these families to lobby for legislation to mandate coverage.
At this time, there is no national legislation to mandate that insurance
companies pay for these treatments. Some states have passed legislation
that mandates the payment for the treatments of children's portwine stains.

The following is a suggested plan of action for appealing the denial of insurance
coverage of a vascular lesion:

1. There may be instances where you need to see a doctor who isn't a member
of your health plan; it's called an "out of network" provider.
If you are seeking "out of network" care, find a doctor who
will support your efforts. Supply your doctor with information from journals,
newspaper articles, or pamphlets that indicates there are new, effective
treatment options available "out of network" The treatment
of vascular lesions is such a new and growing field, your doctor may not
be aware of all the new options available. Share your information since
you need his referral to the "out of network" specialist to
convince the insurance company that it's necessary.

2. Keep a written history of the lesion from birth until present. Document
important information: If the lesion bleeds, becomes ulcerated or infected
make a note of it: as well all hospital or doctor visits related to the
lesion. Document all the expenses related to the care and treatment. For
example: If the lip lesion interferes with eating and you have to buy
special nipples, keep the receipts. This kind of information will be critical
during an appeal process.

3. Seek other opinions that support your need to seek "out of network"
treatment. Find a doctor who will agree to do a phone consult. Send her
any photos, or the results of diagnostic tests such as an MRI that have
been done. Include an extensive description of the lesion and treatments
done to date.

4. If you are denied coverage either verbally or in writing, request a written
explanation. Ask your supporting doctor to request an "Expedited
Appeal." Call your carrier personally and ask the Medical Case Management
Department for the specific steps to appeal the decision. Most carriers
have five to six appeal levels. This is where you get to use the documentation
you've kept regarding the history, expenses, and treatment of the condition.
You don't need a lawyer; most companies allow you to write the appeal
letter yourself.

5. Notify the Benefit's Department of your employer about the denial. The
insurance company may not be following the specific guidelines for your
particular plan. A claims adjuster can make an error or faulty decision.

Your employer may be able to help discover the problem. Although employers
do not usually overrule the insurance company, they can "influence"
the outcome, especially if the carrier is only the administrator of the
plan and not the underwriter. Be sure to show your benefit's person your
pictures and your diary. It makes your case more personal and wins their
support.

6. If you have the name of your claim's adjuster, write or call personally.
This is the person who needs to see your log and pictures. Send them copies
of published articles on hemangiomas or vascular lesions.

7. If you exhaust your appeal process, you may file a complaint with your
state's Commissioner of Insurance Department. Some parents have been very
successful by filing their complaint after the first appeal has been denied.

8. In writing your letter of appeal or your letter of complaint to the Commissioner
of the Insurance Department, there are some key words and phrases that
you should include.

The "quality of life" of the child diminishes due to pain or
discomfort. Pain or discomfort, as perceived by the parent, can be described
by the increased irritability of the child, loss of sleep and period of
crying for unexplained reasons. Remember, if there's bleeding or ulceration,
there is pain.

If the lesion involves an eye or ear, there is a very real potential for
loss of hearing or eyesight when it's left untreated.

List the frequency of bleeding episodes, and the amount of blood loss.

If the lesion affects the throat, cite the life-threatening potential
of airway obstruction without treatment.

If the lesions affect the genital area, point out the potential for infection
due to the contamination as well as the burning associated with urinary
soiling.

State the importance of having a skilled doctor with training in the field
to treat the lesion. You don't want a doctor who has had limited training
and experience on the general use of a laser or someone who "thinks"
he or she can do the procedure.

9. A highly specialized doctor can do a complicated procedure in fewer
treatments than an inexperienced one. If the "out of network"
specialist can reduce the number of surgeries or treatments proposed by
other doctors, emphasize the cost-effectiveness of such an action. This
saves the insurance carrier the cost of more treatments than may be necessary.

10. Contact national and local support groups. They may have more current
information on appealing denial of insurance coverage.

The National Belle Foundation can provide you with a legal letter of support
you can submit to your insurance company.

If your child's lesion is disfiguring, indicate that prompt treatment by
a specialist will save potential psychotherapy treatments down the road
if the child remains untreated by school age.

Make the carrier aware that if these lesions are improperly treated, the cost
to repair the damage will be greater than the cost of an "out of
network" specialist to do the original procedure.

Finally, if you exhaust all levels of appeal, find out who the lobbyist is in your
state for children with special medical needs and tell them your story.
Go to the press. Insurance carriers cannot afford bad press. Good luck!