Vascular Anomalies Center

Insurance

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:

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.
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.
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.
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.
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.
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.
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.
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.
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.
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!