Insurance appeal

July 7, 2006

,We are also with BCBS/FEP, and we are just beginning the process. We are on week 5 of the docband, and I just sent in my claim form to BCBS (for some reason Cranial Tech listed BCBS/IL on the form, and they say that it will go through there, at least initially). We paid CT upfront, with 10% discount, so $2700, and I would love to get any reimbursement possible. Keep me posted if you have any success, and I'll let you know what happens with us.-Crisemily_timberline <emily_timberline@...> wrote: I am having issues with

our insurance paying for the helmet. I called after seeing our physician back in March and the Customer Service told me that the helmet just started being covered January 2006. So I called our Orthotist and told them. The office manager then called our insurance to double check and they told her that it was not covered unless they had the fused skull. We knew that we couldn't put a price on our son's head and health, so we got the helmet. The day of the fitting the office manager at the orthotic clinic called them again. This time asked specifically if this diagnosis code was covered and she said yes, that it just started being covered in Janauary. We got the helmet the end of April and he is a week from getting it off now and I just got a bill saying that they aren't paying. The orthotic office sent a letter with her documentation and the insurance sent one back saying that an oral statement can't

modify or otherwise affect the benefits, limitations, and exclusions of the policy. So, My question is, what is my next step. I am with Blue Cross Blue Shield federal employee plan. Can anyone help me? Thanks

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July 10, 2006

We also have BCBS federal insurance health plan in CA and

my son has been wearing the DOC band for 6 weeks and we are

still waiting for BCBS to pay.

We have called BCBS in May to find out if the band is covered and

the answer was " yes " . So far I have only received a letter from

BCBS telling us that they have requested further information from

Cranial Therapies INC to process the claim.

I have a feeling they might deny our claim too from reading your

post, so please keep us updated the status of your claim. I would

like to find out what to do next if they deny our claim.

Regards

Bonnie

>

> I am having issues with our insurance paying for the helmet. I

> called after seeing our physician back in March and the Customer

> Service told me that the helmet just started being covered January

> 2006. So I called our Orthotist and told them. The office manager

> then called our insurance to double check and they told her that

it

> was not covered unless they had the fused skull. We knew that we

> couldn't put a price on our son's head and health, so we got the

> helmet. The day of the fitting the office manager at the orthotic

> clinic called them again. This time asked specifically if this

> diagnosis code was covered and she said yes, that it just started

> being covered in Janauary. We got the helmet the end of April and

he

> is a week from getting it off now and I just got a bill saying

that

> they aren't paying. The orthotic office sent a letter with her

> documentation and the insurance sent one back saying that an oral

> statement can't modify or otherwise affect the benefits,

> limitations, and exclusions of the policy.

>

> So, My question is, what is my next step. I am with Blue Cross

Blue

> Shield federal employee plan. Can anyone help me?

>

> Thanks

>

September 6, 2006

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?

>

September 6, 2006

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?

September 7, 2006

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

September 7, 2006

I was denied initially as well. They requested a letter of medical

necessity from my nuero-developmental pediatrician and it was approved a

week later...

" jaemegcola "

<jaemegcola@...>

Sent by: cc:

@yaho Subject:

[ ] insurance appeal

ogroups.com

09/06/2006 03:31 PM

Please respond to

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?

September 7, 2006

My child was born with birth defects on his hands and hypospadia

(opening where urine exits in the wrong spot). (An ultrasound showed

he has hydronephrosis; enlarged kidney.) We took him to the

Shriner's in Tampa and they felt he had Streeter's Syndrome

(amniotic band syndrome). From there we went to UCLA and the hand

surgeon/director Dr. Neil Ford felt my son had Poland's

Sequence. When he was 30 mos we took him to a SLP-CCC because he

still wasn't talking. We saw a neurologist and a geneticist and then

United started paying. After we saw our second SLP-CCC and the

neurologist and geneticist was when we had United (before that we

had Aetna HMO).

I am just trying to show that maybe United is paying because my

child has birth defects your doesn't have and that's why they are

paying.

I don't know yet if they are going to pay for OT...

Best wishes,

Debra

> 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

>

September 8, 2006

Try googling " class action lawsuit humana " I'm battling united

right now. Sounds like they could use a class action lawsuit too,

considering how many are having problems. It's been lots of fun

fighting health insurance and home owners RE: Katrina damage. These

insurance " people " surely will get their own ring in hell, if you

ask me.

>

> 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?

>

September 8, 2006

Look at the procedure codes your professionals are using. We had

Blue Cross and have a 20 session limit per year. My son has

appraxia, aphasia (codes are 784.3,784.69 & 784.5)

Let your PT & OT know your codes for speech/language and not to use

any developmental/educational codes. (just medical necessity).

Insurance battles are fought and won every day but you have

to be persistent. What does their policy state as far

speech therapy? Can you tell me the reason for denial?

Ask for the master policy -they will tell you there is none. They

don't like to give it out -but you need a copy for your appeal.

Physicians are busy - if you need a 'good' letter

quoting research then write it yourself and ask the medical

provider if they would be willing to sign on their

letterhead.

Here is an archived letter from Sandy in Illinois:

SAMPLE LETTER:

[DATE]

VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED

[iNSURANCE CO INFO]

To Whom It May Concern:

My son, __________, has been diagnosed with apraxia by his

pediatrician, his

pediatric neurologist, and his speech and language pathologist.

(See enclosed

information). To remediate this condition, has been

receiving

speech and language therapy as well as occupational therapy (the

apraxia affects

his oral motor musculature as well as his fine and gross motor

functions). His

progress has been excellent, and all concerned believe continued

therapy is

crucial to overcome this condition.

[HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT]

Since apraxia is a relatively uncommon condition, let me explain

briefly what

it is. Apraxia " 'is a neurological disorder that affects the

planning and

production of speech. " (, Jakielski, & Marquardt, 1998)'.[it]

is a loss

in ability to voluntarily position the articulators (e.g., lips,

jaw, tongue)

on a consistent basis when speaking. This disorder interferes with

the child'

s sequencing of sounds into words. In other words, the child has

the ability

to produce the sounds, but when he/she tries to purposefully plan

speech, the

articulators do not always function together properly. " S.

Whitebreak, C.

Dvorak, and K. Jakielsi, " Treatment Effect on Speech Intelligibility

in

Developmental Apraxia of Speech, " Presentation at the American

Speech-Language-Hearing

Association, 1999. " '.This disability has a neurological basis of

unknown

origin. It may reflect neuro-anatomical/physiological differences

that are

inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990;

Shriberg, 1993)

or damage that occurs pre- or postnatally during the period of

speech

development (Crary, 1984; Marquardt and Sussman, 1991). " It is

similar to the

condition stroke victims suffer from when they lose the ability to

speak after a

stroke. In fact, many children initially have speech ability but

then lose it

(as is the case with , who had a larger vocabulary at 18

months of age

than when diagnosed at 25 months of age).

As to medical necessity of treatment of apraxia, the American Speech

Hearing

Association (ASHA) defines verbal apraxia as " a medical condition

consistent

with the definition of illness and disease.'a disorder of body

function.' "

(Keystater, the official publication of the Pennsylvania Speech

Hearing

Language Ass'n, Sept.. 1992; Source: ASHA, Rockville, MD).

Apraxia is not a developmental disorder or delay. If left

untreated, my son

will not develop meaningful speech or coordinated fine and gross

motor

abilities. Lack of meaningful speech and fine and gross motor

abilities would result

directly in a deterioration of my son's health and safety, in that

he will

not be able to communicate medical needs and will be unable to

function and do

daily life skills. With treatment, however, the prognosis is good.

In fact,

_____'s progress has been excellent.

Speech and occupational therapy are the recommended treatments for

apraxia

(see enclosed letters). They are the least expensive, least

invasive, and most

successful forms of treatment, are accepted by the medical

community, and are

not implemented for the convenience of the child or therapist. See

also a

Square, " Introduction, " Clinics in Communication Disorders, 4(2)

( " apraxia

is a motor speech disorder in the ability to regulate and control

oral movement

sequences. Apraxia is a separate speech disorder that requires a

motor

treatment, apraxia is remediable if the clinician knows that this

must be the focus

of treatment " ); Penelope Hall, Jordan and

Robin, " Theory and

Clinical Practices " ( " Intensive services are needed for children

with apraxia "

); Edythe Strand, " Childhood Motor Speech Disorder Treatment, " ( " The

earlier

and more intensive the intervention, the more successful the

therapy.Children

with apraxia really need the intensive individual therapy " ).

In fact, the research indicates and experience dictates that apraxic

children

need intensive consistent therapy. The leading researchers in the

field have

indicated that this is the best therapeutic route to take. Such

researchers

include Edythe Strand, PhD., Mayo Clinic; a Square, Ph.D.,

University of

Toronto; and Robin, Ph.D., University of Iowa. The research

indicates

that the key to success is intensive therapy continually throughout

the year.

In short, since apraxia is a medical condition and not a

developmental delay

or disorder, and since speech and occupational therapy are medically

necessary, I submit that the enclosed expenses should be a covered

benefit under the

plan. Thank you for your consideration.

Sincerely,

contact me privately at mulholland34@... if you have any

questions

All the best,

Joanne

September 8, 2006

--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?

> >

>

September 8, 2006

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

>

September 12, 2006

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-

>

September 28, 2006

I am using a letter from the prescribing doctor, as well as an evaluation from the pt stating cranial banding is neccessary. HTH. Candace, AZ mommy to Tiernan, 4.5 mos tort, plagio Holcombe <stacy_holcombe@...> wrote: Did anyone have a letter of medical necessity submitted by their orthotist? Or is this something the pediatrician, neurologist, or PT does? Symborski Media Specialist stacy_holcombe A library is a hospital for the mind. Anonymous Stay in the know. Pulse on the new .com. Check it out.

All-new - Fire up a more powerful email and get things done faster.

November 13, 2006

Hi CrisI have good news. They paid for our helmet. I think after they reimbursed us we ended up paying 150.00 or something, which I was very happy about. I hope you have had good luck as well. Albrecht Re: Insurance Appeal

,We are also with BCBS/FEP, and we are just beginning the process. We are on week 5 of the docband, and I just sent in my claim form to BCBS (for some reason Cranial Tech listed BCBS/IL on the form, and they say that it will go through there, at least initially). We paid CT upfront, with 10% discount, so $2700, and I would love to get any reimbursement possible. Keep me posted if you have any success, and I'll let you know what happens with us.-Crisemily_timberline <emily_timberline@...> wrote: I am having issues with

our insurance paying for the helmet. I called after seeing our physician back in March and the Customer Service told me that the helmet just started being covered January 2006. So I called our Orthotist and told them. The office manager then called our insurance to double check and they told her that it was not covered unless they had the fused skull. We knew that we couldn't put a price on our son's head and health, so we got the helmet. The day of the fitting the office manager at the orthotic clinic called them again. This time asked specifically if this diagnosis code was covered and she said yes, that it just started being covered in Janauary. We got the helmet the end of April and he is a week from getting it off now and I just got a bill saying that they aren't paying. The orthotic office sent a letter with her documentation and the insurance sent one back saying that an oral statement can't

modify or otherwise affect the benefits, limitations, and exclusions of the policy. So, My question is, what is my next step. I am with Blue Cross Blue Shield federal employee plan. Can anyone help me? Thanks Music Unlimited - Access over 1 million songs.

Try it free.

December 19, 2006

Hello everyone, I just thought that I would update you guys on my insurance

appeal. Basically, I'm at square one...Their decision was that they need an

" official " prognosis(I thought that's what I gave) and how long at what cost

will he need therapy. Well, if they would have paid for his eval, they

should know all this...I'm livid. Today, I contacted an attorney. We'll see

what happens. All I know is if they think that if they push me hard enough that

I will give up, they've got another thing coming. The angier I get, the more I

will fight!!! I am NOT giving in!!! Anyway, Thursday, we see a pediatric

neurologist that comes highly recommended. I hope all goes well. I'll let you

know!

December 19, 2006

The following is from SpeechvilleExpress insurance section:

Diagnosis Destinations Apraxia Appealing Insurance Denials Apraxia is

" Developmental " . " Developmental delays " are not Covered.

Reason for Denial: " Apraxia is developmental. Developmental delays are not

covered. "

One of the most important things to do when applying for insurance coverage of

apraxia-related therapy is to ensure that the evaluator (that is, the

speech-language pathologist) does not use the word " developmental " in his or her

report, as in " Developmental Apraxia of Speech " or " Developmental Verbal

Dyspraxia. " While these terms are common in apraxia and speech therapy

literature, for many families these phrases have been the sole cause of denials

of insurance coverage. Insurance companies' claims evaluators see the word

" developmental " and think, " developmental delay. " Most insurance companies and

HMOs do not see it as their responsibility to pay for speech therapy if speech

is developmentally delayed, which they interpret to mean " will improve with

time, with or without treatment " . The person who is denying claims often does

not know that " Developmental Apraxia " is not the same as " developmental delay, "

nor may he or she know that " Developmental Apraxia " is used

primarily to distinguish the condition from " Acquired Apraxia " (the loss of

speech caused by a known incident of stroke or other brain trauma). The

therapist should use a term such as " apraxia of speech, " " oral motor planning

disorder, " or " speech motor disorder. "

The insurance company might also be confusing apraxia of speech with a

" developmental disability " . The United States government's definition of

" developmental disability " requires that the disability be a mental and/or

physical impairment, manifest before the individual is 22 years old, will likely

continue indefinitely, results in substantial functional limitations in 3 or

more major life activities, and will necessitate special services and supports

of either lifelong or extended duration. Apraxia is not a " developmental

disability, " though apraxia can co-occur, in some children, with a developmental

disability. Regardless of whether or not a child is developmentally disabled, in

addition to having apraxia of speech, the insurance company should not deny the

claim on the basis of the developmental disability, if oral motor speech

disorders would otherwise be covered.

Therapists and doctors use diagnostic codes for insurance purposes. Again, the

provider should not code a diagnosis for a child with Apraxia of Speech as

" developmental delay " (code 315.9) or " developmental speech or language " (code

315.31). Codes to use are: a neurological code (codes 340 - 349) or coordination

disorder (code 315.4). It is worth your while to ask the therapist or doctor

(depending on if you need your physician's referral) what diagnostic code they

will use in the report or referral.

If you have already received a denial of insurance because of the

" developmental " confusion, you will need to provide documentation to your

insurance company or HMO demonstrating that apraxia of speech is not a

developmental delay of speech. Apraxia of speech is disordered speech, speech

that is not following a typical developmental path, whereas a child with

developmentally delayed speech has typical speech patterns, albeit those of a

younger child. Sometimes describing apraxia of speech as a neurological disorder

or condition seems to help. Therefore here is a quote about the nature of

apraxia from a well-known speech-language pathologist who specializes in apraxia

of speech in children, Hodge,

" ...This disability has a neurological basis of unknown origin. It may reflect

neuro-anatomical/physiological differences that are inherited (see Hurst,

Baraitser, Auger, Graham, and Norell, 1990; Shriberg, 1993) or damage that

occurs pre- or postnatally during the period of speech development (Crary, 1984;

Marquardt and Sussman, 1991)... "

chadmissy@... wrote: Hello everyone, I just thought that I

would update you guys on my insurance appeal. Basically, I'm at square

one...Their decision was that they need an " official " prognosis(I thought that's

what I gave) and how long at what cost will he need therapy. Well, if they

would have paid for his eval, they should know all this...I'm livid. Today, I

contacted an attorney. We'll see what happens. All I know is if they think that

if they push me hard enough that I will give up, they've got another thing

coming. The angier I get, the more I will fight!!! I am NOT giving in!!! Anyway,

Thursday, we see a pediatric neurologist that comes highly recommended. I hope

all goes well. I'll let you know!

__________________________________________________

December 19, 2006

Thank you for this information! I will be using it in my complaint to the

Dept. of Insurance since my appeal was denied.

Mandy Knapp

Creative Memories Unit Leader

(847) 245-4133

(224) 577-8304

Available Nov. 1st download your free StoryBook software at

www.mycmsite.com/mandyknapp

Action Code 27169225

your life | your story | your way

December 19, 2006