You would think that once you have made the leap and decided to get a helmet for your kid it would be smooth sailing. But ah nay nay, you may have a loooong road ahead of you. For starters, navigating insurance can be one heck of a nightmare. We are talking Lord Voldemort under your bed ready to cruccio you butt kind of nightmare. I am not kidding when I say I spent 50+ hours on the phone with insurance, third party facilitators, and doctor's billing assistants trying to get everything sorted out.
The unfortunate reality is that because plagiocephaly is so new, helmet therapy is often considered alternative, cosmetic, or optional, so coverage is limited. Many insurance companies consider cranial remodeling helmets an aesthetic or alternative treatment, so deny coverage entirely. We THOUGHT we got lucky and would have coverage.
For us, a referral from a general pediatrician was not considered enough evidence for meriting insurance payment of the helmet, so we had to get an appointment with a developmental specialist. Apparently these people are quite popular because it took us nearly a month to get in. At this appointment Jay had his head measured his neck muscles examined. We also detailed his physical therapy history and the doctor deemed that it had been unsuccessful for correcting his head shape. Lucky for us, our doctor was very thorough and spent loads of time laying out the pros and cons of helmet therapy from a developmental standpoint.
Jay's head has right posterior cranial vault asymmetry measuring 13mm. This classifies him as having a moderate deformity and places him several millimeters above the cut off point for which a helmet is warranted both medically and for insurance payment at our particular company. With these measurements, we got the golden ticket (aka the prescription) to proceed with helmet therapy.
Prescription in hand, I spent hours and hours (and hours and hours and hours) on the phone tracking down an in-network orthotic and prosthetic provider in our area. After finding one and having another several week waiting period, I started trying to figure out a solution that would allow Jay to get in his helmet sooner. See, after the original appointment the orthoepist has to get approval from insurance, which can take up to two business weeks. Then Jay would have to be scanned and the helmet has to be ordered. Depending on the company you are working with, that can be another couple weeks. Then there is a fitting and getting the helmet adjusted just right. For us, that was pushing things way to far out. Especially since as the child reaches more milestones, they become more resistant to the helmet and may even try and pull it off.
Anyways, first I filed an appeal to try and get an out of network provider covered in-network because of the long wait time. Rejected.
Then I tried to have another out-of-network provider submit a pre-certification to see if they could be covered. Also, rejected.
In the end, I received a call from some high up person at our insurance company apologizing profusely for having wrong plan information on file and the helmet wasn't actually covered AT ALL under our policy. Many a tears were shed over this. Not for the fact that we now have to pay $2000 out of pocket (did I mention that these things are RIDICULOUSLY pricey?), but for the fact that again my sweet boy was being delayed treatment.
But I've digressed. Onward and upward. We decided to move forward with a company that would be able to get us in quickly and are currently working with the P & O Group at the Children's Hospital of Colorado.
So to make a long story short, before doing anything I would recommend getting in touch with your insurance company. Push and push and push to get documentation in writing. Because it turns out that even if 5+ customer service representatives all tell you you are covered and find an in-network provider for you, you still might not be covered in the end. After talking to many other mama's who have had similar issues with their insurance companies, a lot of times the call center agents don't have great training on the protocol for helmets and can give you the wrong information. #stillbitter
So like I said, make them send you written documentation of your plan and of your coverage. Ask them to send you documentation of their exact requirements for coverage (head measurements, duration in physical therapy, pictures, etc.). Ask to be escalated to a manager if the information you are receiving is not lining up.
Health insurance is awesome, but they are also companies working to make a profit. You have to be your child's advocate and push to get answers, clarity, and assistance.