insurance appeal

[Guest guest]

Using the sensory dysfunction diagnosis is a path to rejection. But

hypotonia should usually get occupational therapy. Have you got a letter of

medical necessity from your pediatrician or developmental pediatrician?

Also include " dyspraxia " in the Dx, another diagnosis in need of

occupational therapy.

[ ] insurance appeal

I am getting ready to appeal my insurance again for occupational therapy.

After two years and reviewing information just provided they have decided

therapy is " maintance therapy "

So we go down the road again to PROVE it's restorative as well as therapy

that cannot and should not be provided for by the school.

Some questions

In the past I have said my son has a dual Dx of Hypotonia and Global

Apraxia..trying to stay away from DSI. Is Sensory Integration Dysfunction

more a recognized disorder by the medical community now so much so I can now

use it as a DX as well?. I don't think there is a DX code for it though.

I have in the past used chronic ear infections from 6mo to 3 years old and

removal of adenoids at 9yo to sight medical conditions that have caused lose

of function...therefore impacting the vestibular system therefore all sense

systems in general. It did work. Now how to a say therapy is still

restorative? I feel it's kind of a catch 22 here children need skills to

acquire new skills just to DEVELOPE but do not want to use the word

development in any way as it is the kiss of death for insurance coverage,

Any ideas?

Thanks for all your help. I will keep you posted.

Ann In Chgo mom to john 11yo

[Guest guest]

I would advise against using Sensory Intregration. We are currently fighting

BCBS of PA (we are in NJ but husbands co in based in PA) for the part of my

son's OT that was coded Sensory Intergration. They are claiming it is

Experimental.

There is a procecure code for DSI that was used and that part was denied. We are

in the third round of appeal. I owe a letter.

19a.

insurance appeal

Posted by: " ann coleman " ann.coleman3@... amc1300me

Wed Jul 12, 2006 10:53 pm (PST)

I am getting ready to appeal my insurance again for occupational therapy. After

two years and reviewing information just provided they have decided therapy is

" maintance therapy "

So we go down the road again to PROVE it's restorative as well as therapy that

cannot and should not be provided for by the school.

Some questions

In the past I have said my son has a dual Dx of Hypotonia and Global

Apraxia..trying to stay away from DSI. Is Sensory Integration Dysfunction more a

recognized disorder by the medical community now so much so I can now use it as

a DX as well?. I don't think there is a DX code for it though.

I have in the past used chronic ear infections from 6mo to 3 years old and

removal of adenoids at 9yo to sight medical conditions that have caused lose of

function...therefore impacting the vestibular system therefore all sense systems

in general. It did work. Now how to a say therapy is still restorative? I feel

it's kind of a catch 22 here children need skills to acquire new skills just to

DEVELOPE but do not want to use the word development in any way as it is the

kiss of death for insurance coverage, Any ideas?

Thanks for all your help. I will keep you posted.

Ann In Chgo mom to john 11yo

[Guest guest]

hi- charlotte henry here- we use lack of coordination for ot and bc- bs

covers it- thee is a 1000 dollar limit on speech so we get medicaid to pick up

the rest-

[Guest guest]

hi- we use lack of coordination for ot with bc bs and they cover

it-charlotte henry

[Guest guest]

My insurance is denying my child speech threrapy under the diagnosis of

verbal apraxia. She must have a congenital anomaly to qualify for

benefits. Is anyone familiar with this struggle, and if so, can you

offer any advice?

[Guest guest]

After I saw a neuro pediatrician my insurance company started paying.

I have United HealthCare HMO. They never sent a letter stating they

would pay they just are. The neurologist gave us physician's orders

staing my son had a neurological problem and he requires speech

therapy.

Best wishes. They still sometimes refuse to pay for some sessions and

my therapist's office has to resubmit many claims for me...

>

> My insurance is denying my child speech threrapy under the diagnosis

of

> verbal apraxia. She must have a congenital anomaly to qualify for

> benefits. Is anyone familiar with this struggle, and if so, can you

> offer any advice?

>

[Guest guest]

Very familiar and not happy..the only thing that has saved us is that my

husband is retired military and we get some assistance with TRICare..I

talked to many specialists at United Health Care even had a very sympathetic

associate whose son was tourettes she gave me 3 additional codes but they

also where not justified or covered by insurance when I refiled for an

appeal...It is so frustrating!!!! I think it should be covered as it is a

neurological based problem not a developmental one....

_____

From:

[mailto: ] On Behalf Of jaemegcola

Sent: Wednesday, September 06, 2006 3:31 PM

Subject: [ ] insurance appeal

My insurance is denying my child speech threrapy under the diagnosis of

verbal apraxia. She must have a congenital anomaly to qualify for

benefits. Is anyone familiar with this struggle, and if so, can you

offer any advice?

[Guest guest]

I have United Health and they told me the same crap!!!!!!!

Lucas was recently diagnosed with hearing loss so they will now start paying

for speech therapy. We start on Monday.

jaemegcola <jaemegcola@...> wrote:

My insurance is denying my child speech threrapy under the diagnosis

of

verbal apraxia. She must have a congenital anomaly to qualify for

benefits. Is anyone familiar with this struggle, and if so, can you

offer any advice?

---------------------------------

Get your email and more, right on the new .com

[Guest guest]

I'm having the biggest battle with Humana to pay for my son's

therapy. They refuse, stating that his problem is an " educational

delay that will resolve itself. " But none of the doctors or

therapists or specialists to which I've sent my son seem to think

that this is an " educational delay, " or that it will " resolve

itself " .

Humana just doesn't want to pay.

My son has had oral-motor dysfunction since birth, as evidenced by

the milk coming out of his nose from breastfeeding and the gagging on

soft foods, that continues to this day. He was also diagnosed with

reflux at 4 months. But most striking is the fact that he was saying

words before he became ill at 11 months, and then stopped. A year

after he got out of the hospital, he started speaking again, but

incomprehensibly. Even words that he was saying before he became ill

were markedly different. If you didn't know him, you wouldn't have

known what he was saying.

I have to exhaust all of my appeals before I can file a lawsuit. Does

anyone know of a class action lawsuit going on against Humana? How

would I find out if one has been filed?

[Guest guest]

--I also have United Healthcare and I am now searching for a

pediatric Neurologist. What has your child been diagnosed with and

would you happen to know the insurance codes your therapist is using?

Also, is there a way around the 20 sessions per year thing

- In , " debjward " <debjward@...>

wrote:

>

> After I saw a neuro pediatrician my insurance company started

paying.

> I have United HealthCare HMO. They never sent a letter stating they

> would pay they just are. The neurologist gave us physician's orders

> staing my son had a neurological problem and he requires speech

> therapy.

>

> Best wishes. They still sometimes refuse to pay for some sessions

and

> my therapist's office has to resubmit many claims for me...

>

>

> >

> > My insurance is denying my child speech threrapy under the

diagnosis

> of

> > verbal apraxia. She must have a congenital anomaly to qualify

for

> > benefits. Is anyone familiar with this struggle, and if so, can

you

> > offer any advice?

> >

>

[Guest guest]

My son's therapist uses " Dysarthria " 784.5. The neurologist used

783.4 which is " neurodevelopmental dysfunction " and 784.69 " apraxia

of speech " .

I don't know how to get around the 20 visits per year other than I

just kept going after I noticed they started paying. No one has told

me they will pay and no one has sent a letter stating they will pay.

My DH says they won't acknowledge it in writing so they can stop

paying at any time and not have to honor the acknowledgment!

>

> --I also have United Healthcare and I am now searching for a

> pediatric Neurologist. What has your child been diagnosed with

and

> would you happen to know the insurance codes your therapist is

using?

> Also, is there a way around the 20 sessions per year thing

>

>

>

[Guest guest]

Henry,

You mentioned that you get medicaid. Is there a salary limit on

Medicaid or is attainable for people with disabilites?

thanks,

-- In , stehn4@... wrote:

>

> hi- charlotte henry here- we use lack of coordination for ot and bc-

bs

> covers it- thee is a 1000 dollar limit on speech so we get medicaid

to pick up

> the rest-

>

>

>

[Guest guest]

yes there is a salary limit on medicaid but there are certain wavers we

qualify for and that is not based on income guidelines like the ill and

handicapped waiver- there may be a waiting list but we have nothing to lose

-charlotte