Q: Are vascular birthmark treatments covered by health insurance?
A: Sadly, many insurance carriers consider this to be cosmetic surgery. However, many patients have successfully convinced insurers that this is not the case. Vascular Birthmark Institute administrative staff can advise you, but there are numerous steps that you may take to help establish your case.
Gain the support of a doctor within your insurance network- Because you will likely have to consult with a specialist who does not participate in your health coverage plan, you will need to gain the support of a physician within your plan network. Provide him or her with as much information as you can about your child's condition. Vascular birthmark treatment is a relatively new and fast growing field, so your physician may not be aware of all the facts and new treatments options.
Keep a diary of your child's condition- Document when you first noticed the lesion, any changes you detect, incidence of bleeding, whether it interferes with the child's eating, speaking or other activities, physician visits, etc. Include dates and descriptions.
Get other options- Find another doctor who will do a telephone consultation. Send him or her photos, medical records, test results, and any other information necessary to support your belief that and out-of-network specialist consultation is necessary.
If denied your claim, obtain a written explanation- As your supporting physician to request an "expedited appeal". Call the Medical Case Management Department of your health insurance company to learn exactly what steps you must take to appeal the denial. Most carriers have several levels of appeal. Hiring an attorney is not usually necessary. Most companies allow you to submit a letter containing precise information about your child's condition. Your diary will be invaluable in preparing this.
Consult with your employer's benefits coordinator- This person is knowledgeable about your employer's policy and can double-check that the insurance company is meeting all the requirements. Bring your diary and photos of the lesion with you to help demonstrate your case.
Try to contact your insurance company claims adjuster. Send this person photos and articles about your child's condition.
If your appeals fail, petition your State Commissioner of Insurance- In your letter to the Commissioner, use key phrases like "quality of life," describe bleeding incidents or the potential for interference with your child's normal activities, such as eating or speaking. Remind the Commissioner that treatment by a specialist will ultimately result in fewer doctor visits and costly complications, ultimately saving money. Some parents have been successful in overturning their insurance carrier's denial this way. If you have any questions, Rachel Demetrius, Practice Administrator and Sherri Foster, parent advocate, can assist you in this process.