Appealing coverage for PT services through Aetna PPO

[Guest guest]

We just recieved notice from Aetna, our insurance provider, that the PT services they'd initially approved (initial approval was for 60 visits) would not be covered. They covered only the evaluation, even though our developmental pedi provided a letter of medical necessity. We are going to appeal.

I'm planning to send them: (a) a copy of the letter of medical necessity from the developmental pedi, ( a copy of the official diagnosis/plan of action received earlier this year, © copies of the evals from OT and PT documenting hypotonia and weakness, (d) a copy of the insurance code (2009 version) which states PT is to be a covered item if deemed medically necessary for any child with an autism diagnosis.

Anything else we should include? Besides a cover letter, that is?

Byrne

Read our kids'stories online at Caring Bridge - http://www.caringbridge.org/visit/prestonbyrne and http://www.caringbridge.org/visit/toribyrne

[Guest guest]

:

If the plan is self-funded, the insurance code might not need to be followed. If your plan is self-funded, you should contact the health administrator of the policy to find out under what instances they have negotiated with Aetna for coverage for those services. For example, with my husband's insurance, they had 4 specific qualifications for which their self-funded plan with their insurance carriers (which ranged from UHC to Aetna to others in the 15 years he was there) would cover speech therapy. They had similar specifications for OT and PT. That is why most employers switched over to self-funded plans -- the insurance companies told them it would reduce their premiums because they could exclude a lot of these issues, including the psychiatric stuff. I'm interested, though, when the mental parity act goes into effect because that law actually included self-funded plans. If an employer offered psychiatric benefits (which includes autism--I understand the argument, but it is still classified in this category), then they have to offer treatment for all DSM codes and not selective ones. The hope is that because of that, ABA would be able to be covered under this new provision. I was less optimistic, because the employers could choose to drop all psychiatric coverage if they have to cover all of them. It was an all-or-nothing cause.

Hilda

Appealing coverage for PT services through Aetna PPO

We just recieved notice from Aetna, our insurance provider, that the PT services they'd initially approved (initial approval was for 60 visits) would not be covered. They covered only the evaluation, even though our developmental pedi provided a letter of medical necessity. We are going to appeal.

I'm planning to send them: (a) a copy of the letter of medical necessity from the developmental pedi, ( a copy of the official diagnosis/plan of action received earlier this year, © copies of the evals from OT and PT documenting hypotonia and weakness, (d) a copy of the insurance code (2009 version) which states PT is to be a covered item if deemed medically necessary for any child with an autism diagnosis.

Anything else we should include? Besides a cover letter, that is?

Byrne

Read our kids'stories online at Caring Bridge - http://www.caringbridge.org/visit/prestonbyrne and http://www.caringbridge.org/visit/toribyrne