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Old 01-25-2010, 08:26 PM
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Harrison Harrison is offline
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Default The Insurance Intelligencer - Jan 25th, 2010


Max's Head

Remember six-month-old Nicholas, who had his skull fixed by Dr. Fearon? It wasn't long before Nicholas from Michigan led to Max from California.

While we were fighting Max's appeal last week, his mom Cassie was wrangling a two-and-a-half year old, and a six-month-old who doesn't sleep. They live in Southern California. Torrential rains were falling, and the power was going on and off.

Our opponent was Anthem Blue Cross of California -- the biggest, baddest, most loaded-for-bear insurance company in the entire country. The last time I faced off with Anthem, they won.

Will the house wash away? Will Laurie be defeated by the Goliath of health insurance? Will Cassie tear off all of her clothes, and run screaming into the street?

What is this surgery, anyhow?

When babies are born, the many sutures that connect the parts of the skull are soft and pliable. They fuse gradually, to allow the brain to grow in just the right directions. In babies with craniosynostosis, one or more of the sutures fuses prematurely. The head immediately takes on an unusual shape.

In order to fix this condition, the skull is taken apart and expertly refashioned, with just the right amount of space left for the brain to grow. The problem is that the surgeon who gets the best outcomes with this surgery is in Dallas, Texas, and he is not contracted with Blue Cross Blue Shield.

With insurance companies, there is a tremendous push to keep us in-network and local -- regardless of the qualifications or expertise of the local in-network surgeons.

Anthem sent Cassie to some fine, fancy, distinguished neurosurgeons in Los Angeles. She was very comfortable with them. The only reason why she decided to fight to get to Dr. Fearon was because the local surgeons all told her that catastrophic bleeding is a common complication of this surgery, and Max would definitely need a transfusion. Dr. Fearon has made innovations that drastically reduce the rate of transfusion.

It was the transfusion that bothered her. Little did she know that it was the type of surgery that the local surgeons were offering that should have given her pause.

The Pi-procedure

I had Cassie write Max's medical story. Then, I questioned her, "What did the surgeons tell you about the surgery that they would do for Max? How did they describe it? What did they say?" I need to know what the in-network doctors are offering, so that I can contrast it with the elegant posterior cranial vault remodeling performed by Dr. Fearon.

Try as I might, I could not figure out what they were doing. It was all very murky and vague. What was this surgery being performed in Los Angeles?

I was able to find an article by a nurse at Children's Hospital in Los Angeles, describing the surgery that they do there. I still couldn't figure it out. How was I ever going to make this clear to Anthem?

Finally, I sent the article to Dr. Fearon, who replied, "This article describes a type of strip craniectomy called the Pi-procedure."

Ah, the Pi-procedure! It is not the same as what Dr. Fearon does. The skull remodeling is so simple that a neurosurgeon often performs it without the assistance of a cranio-facial surgeon. The doctor cuts out the fused suture, and discards that part of the skull. He then cuts out two strips next to it, and joins the whole business together with plates and screws.

I crafted the thirty-four-page appeal, complete with diagrams, and sent it to Cassie. She called me, "I had no idea."

"They didn't explain it to you, did they?" I replied.

We have a dream

When people lose an appeal, I counsel them to do things differently the next time. Last time, when I lost to Anthem, I came out with all guns blazing. This time, I held back a little bit. I decided that, with Anthem being so big and powerful -- if I came out swinging, they would hit me upside the head with a 2 x 4.

So, I softened my approach. There were no titles like, "Anthem BC of CA violates state law such-and-such." I stated all of the powerful facts. However, I also gave Anthem a degree or two of slack, to leave a little room for compassion to rush in and fill the vacuum.

I deployed the appeal copies by fax and email on Sunday night, as usual. I forgot that Monday was Martin Luther King day.

The compassionate Buddhas must have been watching, because the holiday turned to our advantage. One of the many executives to whom I addressed the appeal was working on Monday. High-level executives at insurance companies are instructed never to read appeals, of course. I make them as irresistable as possible, to overcome that obstacle.

Our executive sent me a very respectful reply on Monday evening, and told me that he would handle it. (These higher-ups often think that I am the insured person, because the email or fax comes from me.) I believed him.

The next day, Cassie heard from Anthem -- "We're working on it." On Thursday, the surgery with Dr. Fearon was approved.

Cassie did not run screaming into the street, the house didn't wash away, and Laurie had her sweet victory.

Best of all, little Max will have his surgery.



Happy and peaceful Insurance Warrior-ing,
Laurie Todd
www.theinsurancewarrior.com


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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
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