Insurance denial - HELP!

[Rick]

My 10 year old daughter is due for rhinoplasty to correct the appearance problems due to her cleft lip/palate. We are being denied due to the insurance company's claims it is simply cosmetic in nature. We need suggestions on how we should formulate our appeal.

[Susan]

At one point the Cleft Palate Foundation web page mentioned a piece of legislation for children with disabilities. If passed, this would make it illegal for insurance to deny claims based on "cosmetic" reasons for ANY surgeries assiciated with a birth defect, including plastic surgery for cleft lip/ palate correction and revision. Does anyone know if this went through or how to find out??????? It would make a big difference to all of us!

[Carol]

I have a unilaterial cleft lip/palate. I had the same thing happen to me once. When I was 24 I was going in for more surgery and the insurance I had then tried to deny coverage for the very same reason--that it was cosmetic. I went to the next "level" up in the insurance company and submitted again for pre-approval. (Basically I resubmitted it.) I also talked to my Human
Resources personnel. They told my that if it gets denied again that my case would then go to an independent group outside the insurance company. That is what ended up happening because the insurance company denied it a second time. So it went to this 3rd party group and whatever this group decided is what my insurance company HAD to follow. The independent group approved it! Insurance HAD to pay for it. It takes some fighting and it takes time. It took my about 9 months before I finally had my surgery. But keep fighting the insurance company. DON'T TAKE NO FOR AN ANSWER.

[robinsi2000@yahoo.com]

I would like to know also if it has gone anywhere. We got denied for out of network yesterday. We have to pay for the clinic using the deducticable. We have medcial access which will pick it up but to be denied because they don't want to pay for this center we have chosen is not right.