September 29, 2009
Anthem Blue Cross
RE: Benjamin Garrett
Dear Blue Cross Anthem Preauthorization Department:
I am writing to you in regards to a request submitted by Dr. Charles Mace and Dr. Douglas McNeal for Benjamin Garrett to receive services at St. John’s Hospital with Dr. Sami Khoshyomn. Anthem Blue Cross has denied coverage because St. John’s Hospital is out of my HMO network.
Dr. Mace performed Benjamin’s first brain surgery at Cox Hospital when Ben was fourteen weeks old. However, Benjamin’s skull has closed again and he requires an additional surgery. Dr. Mace is not a pediatric neurosurgeon, and because second surgeries are so uncommon, we have sought treatment with a pediatric neurosurgeon.
Dr. Khoshyomn is the only pediatric neurosurgeon in the region. Over the past two and a half years, Dr. Khoshyomn has performed over forty surgeries in children who also have craniosynostosis, Benjamin’s condition. His method involves inserting absorbable plates and screws to keep the bones apart, followed by three to sixth months in a molding helmet. Dr. Khoshyomn has had such positive results with this method, that no children have required a second surgery. Cox does not have a pediatric neurosurgeon on staff.
Benjamin needs this surgery soon. If we wait beyond his first year of life, his bones will not be able to regenerate and fill the void created by the needed surgery and he will need artificial bone grafts implanted later, as a young child. This surgery is necessary for Benjamin’s skull to open to provide adequate brain growth, in order to prevent the possibility of seizures, blindness, and major developmental delays.
Additionally, Benjamin is facing living with a physical deformity and I truly believe it is too much to ask of him that he simply live his life with this deformity and its complications when there is a proven medical procedure available to correct it.
For these reasons, we are seeking Blue Cross Anthem to make an exception in Benjamin’s coverage, to include surgery performed by Dr. Khoshyamn and all of the associated hospital and medical expenses through St. John’s Hospital in Springfield, Missouri. Should you need any additional information, feel free to contact us at XXX-XXX-XXXX. Thank you for your time and assistance in this matter.
Josh and Lara Garrett
A record of phone conversations between Mr. and Mrs. Garrett and Blue Cross Anthem representatives (5 pages).
A patient story of Dr. Khoshyomn's that explains the procedure he has also proposed for Benjamin. This article also covers the possible complications of Benjamin's condition if left untreated.
Referral letters from Dr. McNeal, Ben's pediatrician, and Dr. Mace, Ben's original surgeon.
That letter, those documents, and an extensive phone conversation between Dr. Sami Khoshyomn and Blue Cross Anthem were enough to persuade the insurance company to cover Benjamin's surgery and provide us with in-network level coverage. They are still denying coverage of the helmet due to its "experimental" nature, but in the big scheme of things, that's a minor issue. We are so relieved to have won our appeal and, as Josh said earlier today, now we just have to get through brain surgery. Our next appointment with the surgeon is scheduled for October 12th, and we will be setting a surgery date at that time.