Insurance issues

SUSAN - posted on 12/23/2008 ( 11 moms have responded )

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I have a 2-year-old son who was diagnosed with SPD about 4 months ago by the OT at his feeding clinic. He currently receives OT and speech through our school district - speech every week and OT every other. Our 10 OT hours will be running out soon, and with his continued eating difficulties and sensory issues, we are trying to get some OT through our insurance. Our insurance company is supposed to be one of the worst for approving therapy, especially when it is not considered a "medical necessity". (Oh, but erectile disfunction drugs are a medical necessity. I'll never understand that one.) Does anyone have any advice about how to go about getting coverage for SPD? Are there any special buzz words that we should be using or not using? I'm assuming our initial request will be denied, which means we will have to appeal and submit letters from us and our docs explaining our case. This whole thing is really stressing me out. I would appreciate any help/advice. Thank you.

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Amie - posted on 12/27/2008

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Hi, I don't have codes numbers for you, but I can tell you that my insurance would not cover "sensory intergration therapy" but my daughters doctor wrote a prescription for OT and PT for "an unspecified disorder of the nervous system" and it was accepted by the insurance. I received this advice from the hospital where she receives therapy. You may want to give the facility where your child will be receiving therapy, a call and ask them for the insurance codes so that you can check to see what might be covered and ask them if they have any advice. I know that this is incredibly frustrating. I hope this helps. Good Luck to you!!

Kind Regards,

Amie

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Sara - posted on 03/31/2014

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I have a nine year old that was diagnosed with SPD last year it took 3 years to diagnose him. We started OT last year I have been battling with our insurance to cover and they keep coming up that he falls out of the neurological disablilites for his age which I guess is 7 and under. Help I don't know how to appeal or what codes should we try to get this covered by our insurance we have OT but won't pay.

Amie - posted on 10/03/2012

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Hi Susan, I am so glad to hear the great news!! I know this has been a long road for you and your family! I am thrilled for you that the 'unspecified' diagnosis worked for you and equally thrilled that you shared your good news!! Thank you for keeping us updated!!



Amie

SUSAN - posted on 10/03/2012

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Wow! I can't believe it's been so long since I originally posted this thread. I'm happy to report that we finally got my son's OT covered and he has been in therapy for almost 3 1/2 years. Our OT also used the "non-specified disorder of the nervous system" for the diagnosis, which is what got us in. We've had some snags along the way, like when they magically decided that he didn't need OT anymore when we met our deductible one year. Once they realized we were going to "fight" their decision with our OT's documentation and doctor's support, we have had no problems getting it renewed each time. OT has helped tremendously! After his last review, he is really close to meeting his goals. Thanks everyone for the responses!!



Susan

Cheryl - posted on 10/03/2012

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try getting a letter of necessity from your Occupational therapist....especially if your child has OT services in school If the child is in a daycare a letter from a teacher stating that the child may benefit from outpatient OT services may help also) . Sometimes this helps with explaining why treatment is necessary especially from

a developmental standpoint. You can also get your daughter to provide a letter of necessity if your child does not attend a daycare.



Hope this helps!

Cheryl

Jaime - posted on 01/27/2009

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I can't really help you with what to tell them but my 3 year old receives therapy through the school's CPSE program and my 6 year old gets it 1 out of every 6 days of school paid for by the school. My 2 year old gets speech and OT 2 times a week paid for by the county. All i can say is if those people won't help you try to get into a developmental pediatrican and maybe they can help with a diagnosis that your insurance can cover. I understand stupid insurance I have to drive 1 1/2 hours away to go see any doctors that take my insurance. I would also write a letter to your local and state representatives and senators telling them of your experience and asking they put more aid into your county or school district. Sry, I couldn't give you better advice but good luck!

Lori - posted on 01/22/2009

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Hi! At age 2, my son was diag with SPD (sensory-seeking) via Ohio's "Help Me Grow" program. Also, with speech issues. The Early Intervention Rep completed an IFSP (Individual Family Service Plan)> Our state program covered OT and SLP a few times a month. At age 3, we found private professionals. Our insurance covered the OT and SLP. Unfort, the OT facility that we were going to closed down after 6 mo's. I was not able to find an OT who specialized in SPD until recently. When the new OT contacted the insurance with various codes, the insurance continued to deny coverage. When I asked the rep why it was covered before and not now, she said it was due to the code the first facility used. I asked for the code but was told that it is illegal to tell me. Hummm I'm paying for the insurance and the therapy but I can't find out the codes. She just told me to have the OT continue to try codes until one works. How pathetic. In the mean time, my son has no OT. Thankfully, I learned a lot from the first OT to keep it somewhat under control. (oh ya, cutting out red dye - all #'s - out of his food/drinks has helped a lot!) However, he is now 4 and I need new advice from an OT. I'm going to try what Amie uses - "an unspecified disorder of the nervous system" - to see if it works. Just had a thought, since your son is not yet 3 yrs old, see if the insurance covers "early intervention issues". If I ever find a code that works, I'll def post it on this site. Good luck.

SUSAN - posted on 01/17/2009

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Yep, just as I thought - insurance denied OT because their "experts" believe Erik's problem is related to developmental delay, which is not covered under our plan. We haven't decided if it's even worth an appeal, but we will explore some of your suggestions. I also spoke to our case worker through the school district, and she was going to see if they could do more with the feeding. I've got my fingers crossed.

SUSAN - posted on 12/30/2008

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Thanks to all of you for the good ideas/suggestions. It's so great that we have this "community" to go to for help!

Chelsea - posted on 12/27/2008

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Hey there! Hang in there hun there is light at the end of this tunnel. I Have had the same problem, fortunatley my husbands private ins just changed our coverage from a 2000 dollar limit to 30 visits for each kind of therapy per person. I cried when that happend. There may be some non profit orginaizations out there that may help you purchase theraputic equip to use at home. Thats how we were able to purchase our sons $160 headphones for the listening therapy he does. We participated in the HEALTHY START program which is a fed funded program and its in every state even if you arent elligable for the pogram thye may have some resources or numbers you can utilize. (now if i could only get the head phones on him...) I encourage you to glean as much as you can from other moms your OT and your community resources, your local ESD or web research. I have several friends who are special ed teachers so if you have a question i could always ask them, many of them are moms who fell into special ed teaching bc they have spd kids or kids who ahve autism who have severe sensory issues. The therapies they try and advice they give are so pivitol for my son and our family. I never knew what theraputic brushing or theraputic listening was til i saw my friend using it on her daughter, this little girl used to take 3 hrs or more of screaming and timeout or positive reinforcement to eat her meals. now after intense OT and continuing use of the things done in OT at home this girlk has made SO MUCH PROGRESS. There is hope and you can do it! By the way that idea two posts down is a great idea, finding the right dr is also so awesome once you get one that works well for you and will partner in the fight to help your child be the best they can be. But in the event you have hit walls you can always post or contact my facebook and i'll see what i can dig up for you, its not insurance coverage but it might help. I had to do what I could til we could get more OT whether conventionally or not. I thought i couldnt do it and that we'd make no progress w/o it but so far no matter how slkow there is progress. oh i almost forgot... if you happen to qualify for state aid of anykind like WIC or anything you may be able to put your son on state health ins as a secondary ins, thats also how i got around some rules. Just got to fight a bit to get those extra OT sessions covered, or actually fin his 10 prescribed sessions, we only got to fin 5 before our ins ran out 6 mths ago. Any ways keep it up we are all here for you and every day is a new day! keep smilin!

Chelsea

Robin - posted on 12/23/2008

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Well I am sorry but I don't have much advice for you. Our insurance O.T visits will also be running out soon & it won't renew til March. We would then spend $240 for every weekly visit, man that hurts. I'm not sure what we are going to do, but some things that pop into my head are: Asking the O.T. for techniques you can do at home (to lengthen time between visits) We have purchased a pressure vest for Owen to wear at school & home, and we will be installing a hammock swing this weekend. I had one of my friends who has an Autistic child tell me that she hired a O.T. student to come in to her home. It was cheaper than a full fledged O.T. & the student needed the clinical hours. Or if all else fails, ask the O.T. office if you can work out some sort of payment/discount plan (it's worth a try.) I doubt that my suggestions will help, but I just wanted you to know that we care & want to help. Although we may not be able to.

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