Topamax and Cleft Palate: Now the Insurance Battle

March 21st, 2011. By AbiK

Hooding Eyelids? Cosmetic elective surgery. Frown lines and laugh lines? Cosmetic elective surgery. Cleft Palate? Cosmetic elective surgery.

Wait—what was that last one?

That’s the incredulous moment a number of parents experience after submitting insurance claims for their child’s cleft palate surgery. They find themselves hearing that their insurance company deems the surgery as either “cosmetic” or “dental”. Translation: You’re on your own. And it doesn’t help to see those ads all over of children with cleft palates in foreign lands for whom there are constant requests for charitable relief. Not that those children don’t deserve assistance—they do—but it leaves folks closer to home questioning whatever happened to that phrase, “charity begins at home”?

Well, insurance companies aren’t in the charity business.

For parents of a child who’s been born with a cleft palate or cleft lip due to Topamax side effects—ie, a birth defect directly related to the mother having taken Topamax during the first trimester, navigating the world of insurance claims and denials is an unexpected battle. But there are some things you can do. Here, some tips from Cleftline.org, the website of the Cleft Palate Foundation:

1. If your insurance company denies your child’s cleft palate surgery claim, make sure you review your insurance plan—some policies have a clause for genetic birth defects that requires coverage for any medical treatment that is necessary because of a birth defect.

2. Try to talk with a case manager—not the customer service person who’s just following the insurance company script. The case manager typically has a medical background and may be better informed and versed in understanding your situation.

3. If your insurance provider deems cleft palate surgery as cosmetic, you can submit an appeal but you should have your doctor write a letter on your behalf to state the medical reasons why the surgery is necessary. A reviewer with the insurance company may not understand that their are benefits to having cleft palate surgery beyond boosting self-esteem. The Cleft Palate Foundation also suggests submitting pictures as well.

4. If your insurance provider says the cleft palate surgery is dental, not medical, try to have a plastic surgeon review your claim. Additionally, have your surgeon and primary physician write letters of support to be submitted to the insurance company. In the letters, ensure that the medical reason for the cleft palate surgery is stated, and that it is necessary, not some elective procedure.

5. If your child also has speech difficulties associated with the cleft palate, ensure that you document with the insurance company—and your doctor can state this in his letter also—knows that the condition is a direct result of the initial birth defect—not the result of an interim surgery or other condition. Otherwise the insurer may consider the speech problem as a secondary condition.

6. If your insurance company considers the cleft palate as a pre-existing condition, understand that many times—and particularly in this economy when many are still going without health insurance to get by—that insurance companies often receive claims from individuals who only sign up for benefits right before they know they will need to file a claim. The Cleft Palate Foundation suggests that you do not let your benefits lapse because you then may become at risk for this type of claim denial.

For more information and for further cleft palate resources, visit the Cleft Palate Foundation at cleftline.org, or call at 800-24-CLEFT. For more information regarding Topamax birth defect legal help and news see our Topamax news page.

Tags: Cleft Palate, Insurance Claim Denial, Insurance Claims, Topamax, Topamax Birth Defects, topamax-birth-defects-topiramate-lawsuit

This was posted on Monday, March 21st, 2011 at 10:54 am and is filed under Drugs/Medical, Emerging Issues, Insurance . Feel free to respond, or trackback. Read our comments policy.