Guest guest Posted September 14, 2002 Report Share Posted September 14, 2002 , Let me know what state you live in, and I will look for laws that might help. ~ Vicki > My insurance has just denied my son's OT and speech because they don't cover " maintenance " therapy (despite weekly progress reports they were sent by the therapist which showed progress!). I am planning to appeal but am having a hard time starting from a blank page. Has anyone fought this battle before who would be willing to share some letters with me? I talked to Dr. Goldberg's office and they said he would probably modify and sign something if I draft it. I just want to explain that this is a medical condition and that he is getting better, so it is not just maintenance of a developmentally delayed child (they don't cover " developmental delay " either - of course!) > Any help would be greatly appreciated. You can e-mail me privately if you wish. > Thanks, > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 14, 2002 Report Share Posted September 14, 2002 Vicki, I'm in Illinois. My employer is self-insured - I know that might make a difference. We have BCBS-PPO. It's frustrating because they have been covering the OT for a year and then suddenly cut us off. I am still waiting for a written explanation. " Developmental Delay " and " Maintenance " are the words they keep throwing at me. Thanks for your help. >From: " mm_mommy " <vberrey@...> >Reply- > >Subject: Re: Insurance letter >Date: Fri, 13 Sep 2002 23:31:28 -0000 > >, > >Let me know what state you live in, and I will look for laws that >might help. > >~ Vicki > > > My insurance has just denied my son's OT and speech because they >don't cover " maintenance " therapy (despite weekly progress reports >they were sent by the therapist which showed progress!). I am >planning to appeal but am having a hard time starting from a blank >page. Has anyone fought this battle before who would be willing to >share some letters with me? I talked to Dr. Goldberg's office and >they said he would probably modify and sign something if I draft it. >I just want to explain that this is a medical condition and that he >is getting better, so it is not just maintenance of a developmentally >delayed child (they don't cover " developmental delay " either - of >course!) > > Any help would be greatly appreciated. You can e-mail me privately >if you wish. > > Thanks, > > > _________________________________________________________________ Chat with friends online, try MSN Messenger: http://messenger.msn.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 14, 2002 Report Share Posted September 14, 2002 Years ago we got OT extended when my son's doc wrote a letter stating that his malabsorption caused by a pathogenic bacteria in his digestive tract was causing him to have motor difficulties and that as he healed from this, he would need the therapy to regain lost skills. Sorry, I have no idea what I did with the letter, but it was pretty straight forward. Perhaps Dr. G can talk about how the immune system problems are leading to motor issues which is treatable but your child will need to continue therapy to regain skills that are being affected due to this? Gaylen Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 14, 2002 Report Share Posted September 14, 2002 Sorry for the blank e-mail, my mouse has a mind of its own today. Our OT approval was an extension of services that insurance was providing before. Every few months, they would deny and we'd have to come up with a way to get more. We never go speech through them because the company was " self-insured " so they didn't have to follow our state's law that says if you cover speech, you have to cover it for all conditions. Gaylen Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 15, 2002 Report Share Posted September 15, 2002 , IL does not have a parity law that mandates coverage for developmental delays, so that won't help you. My suggestion is to find out what diagnosis code(s) are being used to bill. Make sure the codes are for a neurological condition rather than developmental. Then in your letter, explain the services are for the neurological disorder to help your child be able to do things independently, cope with noises or whatever his specific issues are. OT can be for regaining skills lost due to stroke, accident, etc. so in your son's case they need to know this is a lifetime issue, not an issue or regaining lost skills. Hope this is helpful. > > > My insurance has just denied my son's OT and speech because they > >don't cover " maintenance " therapy (despite weekly progress reports > >they were sent by the therapist which showed progress!). I am > >planning to appeal but am having a hard time starting from a blank > >page. Has anyone fought this battle before who would be willing to > >share some letters with me? I talked to Dr. Goldberg's office and > >they said he would probably modify and sign something if I draft it. > >I just want to explain that this is a medical condition and that he > >is getting better, so it is not just maintenance of a developmentally > >delayed child (they don't cover " developmental delay " either - of > >course!) > > > Any help would be greatly appreciated. You can e-mail me privately > >if you wish. > > > Thanks, > > > > > > > > > > _________________________________________________________________ > Chat with friends online, try MSN Messenger: http://messenger.msn.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 23, 2002 Report Share Posted September 23, 2002 what state are you in? in California, there is bill AB88 which mandates ins companies to pay for certain therapies. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2003 Report Share Posted February 6, 2003 On the clos website you send in the info and the office prepares the letter for you. Search for insurance and you should find what you need. I am waiting for mine. V Insurance Letter Does anyone have a copy of the letter they sent to their insurance company explaining the benefits and necessity of the WLS? I thought I saw on the message board where someone had composed a great letter for the insurance co. and then sent it to the rest of us to adopt to our personal situations? I can't find the email or the letter. Any help would be appreciated. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 1, 2004 Report Share Posted December 1, 2004 Hi Tish! I can't open your attachment (says " not stored " )...can you try again or forward it to my personal email? I'm curious what it says...they didn't give me too much of a run-around, but you never know. I certainly haven't seen any reimbursements yet. > I am going to call CT today to have them explain and call my insurance > company but has anyone gotten a letter like this. Not exactly sure what it > means or if I have to do anything to convince them it is medically > necessary. It says I don't but I am WAY confused. Any insight? > > To in Cleveland did you get this letter as I think we have similar > insurance. > > Tish > Teagan 4/25/04 > Plagio/Tort/DOC band 11/26/04 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 1, 2004 Report Share Posted December 1, 2004 Let's try it again! Tish Teagan 4/25/04 Plagio/Tort/DOC band 11/26/04 Re: Insurance Letter > > > Hi Tish! > > I can't open your attachment (says " not stored " )...can you try again > or forward it to my personal email? I'm curious what it says...they > didn't give me too much of a run-around, but you never know. I > certainly haven't seen any reimbursements yet. > > > > > > > I am going to call CT today to have them explain and call my > insurance > > company but has anyone gotten a letter like this. Not exactly sure > what it > > means or if I have to do anything to convince them it is medically > > necessary. It says I don't but I am WAY confused. Any insight? > > > > To in Cleveland did you get this letter as I think we have > similar > > insurance. > > > > Tish > > Teagan 4/25/04 > > Plagio/Tort/DOC band 11/26/04 > > > > > > > For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 1, 2004 Report Share Posted December 1, 2004 Thanks that is kind of what I thought but wanted to double check. I am actually on hold right now! Tish Teagan 4/25/04 Plagio/Tort/DOC band 11/26/04 Re: Insurance Letter > > > Reading that, I think it's saying that you have been approved based > on your predetermination report, you cannot be paid yet because no > services have been rendered (at the time of the letter), there is no > further medical review necessary. Congrats! It's also warning you > that if you go out of network (according to karen, CT is out of > everyone's network) you will be partially financially responsible, > call customer service to find out how much. I don't know how similar > our plans are, but we have a $250 deductable and insurance covers > 70%. > > The words were small so I may have mis-read something, but I think > you're good! > > > > > > > > > I am going to call CT today to have them explain and call my > > > insurance > > > > company but has anyone gotten a letter like this. Not exactly > sure > > > what it > > > > means or if I have to do anything to convince them it is > medically > > > > necessary. It says I don't but I am WAY confused. Any insight? > > > > > > > > To in Cleveland did you get this letter as I think we have > > > similar > > > > insurance. > > > > > > > > Tish > > > > Teagan 4/25/04 > > > > Plagio/Tort/DOC band 11/26/04 > > > > > > > > > > > > > > > > > > > > > For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 1, 2004 Report Share Posted December 1, 2004 I called and it is COVERED! They said though that we will owe 80% but could be more if MMOH doesn't agree with the cost of the band. So we will see. Tish Teagan 4/25/04 Plagio/Tort/DOC band 11/26/04 Re: Insurance Letter > > > > > > > > Reading that, I think it's saying that you have been approved based > > on your predetermination report, you cannot be paid yet because no > > services have been rendered (at the time of the letter), there is no > > further medical review necessary. Congrats! It's also warning you > > that if you go out of network (according to karen, CT is out of > > everyone's network) you will be partially financially responsible, > > call customer service to find out how much. I don't know how similar > > our plans are, but we have a $250 deductable and insurance covers > > 70%. > > > > The words were small so I may have mis-read something, but I think > > you're good! > > > > > > > > > > > > > > > I am going to call CT today to have them explain and call my > > > > insurance > > > > > company but has anyone gotten a letter like this. Not exactly > > sure > > > > what it > > > > > means or if I have to do anything to convince them it is > > medically > > > > > necessary. It says I don't but I am WAY confused. Any insight? > > > > > > > > > > To in Cleveland did you get this letter as I think we have > > > > similar > > > > > insurance. > > > > > > > > > > Tish > > > > > Teagan 4/25/04 > > > > > Plagio/Tort/DOC band 11/26/04 > > > > > > > > > > > > > > > > > > > > > > > > > > > > For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 1, 2004 Report Share Posted December 1, 2004 Tish, It doesn't sound like you were denied. It sounds like they are saying you don't need anymore paperwork but they aren't telling you it's covered. It's very strange. I've never seen anything like it. Hopefully CT can help. mom to na DOC Grad 2/20/04 Tort Resolved SCJ & J <baz@...> wrote: I am going to call CT today to have them explain and call my insurancecompany but has anyone gotten a letter like this. Not exactly sure what itmeans or if I have to do anything to convince them it is medicallynecessary. It says I don't but I am WAY confused. Any insight?To in Cleveland did you get this letter as I think we have similarinsurance.TishTeagan 4/25/04Plagio/Tort/DOC band 11/26/04For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 2, 2004 Report Share Posted December 2, 2004 I called the insurance company and they said that it is covered but that they may not agree to the price. So I may still have to appeal as I know my brother went though this with their insurance company. Said they would cover it then sent them a check for $300. So my fight may not be over but atleast they "say" they will cover it! TishTeagan 4/25/04Plagio/Tort/DOC band 11/26/04 Re: Insurance Letter Tish, It doesn't sound like you were denied. It sounds like they are saying you don't need anymore paperwork but they aren't telling you it's covered. It's very strange. I've never seen anything like it. Hopefully CT can help. mom to na DOC Grad 2/20/04 Tort Resolved SCJ & J <baz@...> wrote: I am going to call CT today to have them explain and call my insurancecompany but has anyone gotten a letter like this. Not exactly sure what itmeans or if I have to do anything to convince them it is medicallynecessary. It says I don't but I am WAY confused. Any insight?To in Cleveland did you get this letter as I think we have similarinsurance.TishTeagan 4/25/04Plagio/Tort/DOC band 11/26/04For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 8, 2008 Report Share Posted May 8, 2008 Not sure if everyone else got this from their insurance companies or not.. but I got a letter stating the following from Aetna yesterday in the mail. Now why the law was passed last June and we are just not receiving the information is beyond me.. but I know I'm going to be appealing some claims that were denied and using this letter as my rason for why.. Take care all! J Re: New Washington DC legislation - Children's Habilitative Sevices Dear Member: This is to notify you that Washington DC has passed a law effective June 1, 2007, which provides coverage for Children's Habilitative Serices. With the exception of early intervention or school programs, habilitative services means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child under the age of 21 with a congenital or genetic birth defect to enhance the child's ability to function. These defects are existing at or from birth, including a hereditary defect. The term " congenital or genetic birth defect " includes autism or an autism spectrum disorder and cerebral palsy. These Habilitative services may need to be precertified by Aetna. If you have any questions, please call Member Services at the toll- free number on your ID card. Sincerely, Aetna Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2008 Report Share Posted May 13, 2008 I have Aetna and have never received anything like this. In fact, last time I checked into my policy, I still had an exclusion for speech and occupational therapy resulting from developmental delay, including autism. > > Not sure if everyone else got this from their insurance companies or > not.. but I got a letter stating the following from Aetna yesterday > in the mail. Now why the law was passed last June and we are just > not receiving the information is beyond me.. but I know I'm going to > be appealing some claims that were denied and using this letter as my > rason for why.. > > Take care all! > > J > > Re: New Washington DC legislation - Children's Habilitative Sevices > > Dear Member: > > This is to notify you that Washington DC has passed a law effective > June 1, 2007, which provides coverage for Children's Habilitative > Serices. > > With the exception of early intervention or school programs, > habilitative services means services, including occupational therapy, > physical therapy, and speech therapy, for the treatment of a child > under the age of 21 with a congenital or genetic birth defect to > enhance the child's ability to function. These defects are existing > at or from birth, including a hereditary defect. The > term " congenital or genetic birth defect " includes autism or an > autism spectrum disorder and cerebral palsy. > > These Habilitative services may need to be precertified by Aetna. > > If you have any questions, please call Member Services at the toll- > free number on your ID card. > > Sincerely, > Aetna > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 14, 2008 Report Share Posted May 14, 2008 You might wanna call Aetna... I called and was able to easily appeal claims that were denied last fall that they have now paid... > > > > Not sure if everyone else got this from their insurance companies > or > > not.. but I got a letter stating the following from Aetna yesterday > > in the mail. Now why the law was passed last June and we are just > > not receiving the information is beyond me.. but I know I'm going > to > > be appealing some claims that were denied and using this letter as > my > > rason for why.. > > > > Take care all! > > > > J > > > > Re: New Washington DC legislation - Children's Habilitative Sevices > > > > Dear Member: > > > > This is to notify you that Washington DC has passed a law effective > > June 1, 2007, which provides coverage for Children's Habilitative > > Serices. > > > > With the exception of early intervention or school programs, > > habilitative services means services, including occupational > therapy, > > physical therapy, and speech therapy, for the treatment of a child > > under the age of 21 with a congenital or genetic birth defect to > > enhance the child's ability to function. These defects are > existing > > at or from birth, including a hereditary defect. The > > term " congenital or genetic birth defect " includes autism or an > > autism spectrum disorder and cerebral palsy. > > > > These Habilitative services may need to be precertified by Aetna. > > > > If you have any questions, please call Member Services at the toll- > > free number on your ID card. > > > > Sincerely, > > Aetna > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 15, 2008 Report Share Posted May 15, 2008 You live in Ne Ohio right? I wonder if Aetna is headquartered in DC and that's why they fall under this local legislation??? -- In , " If you want to know.. Ask! " <mystique2574@...> wrote: > > You might wanna call Aetna... I called and was able to easily appeal > claims that were denied last fall that they have now paid... > > > > > > > > Not sure if everyone else got this from their insurance companies > > or > > > not.. but I got a letter stating the following from Aetna > yesterday > > > in the mail. Now why the law was passed last June and we are > just > > > not receiving the information is beyond me.. but I know I'm going > > to > > > be appealing some claims that were denied and using this letter > as > > my > > > rason for why.. > > > > > > Take care all! > > > > > > J > > > > > > Re: New Washington DC legislation - Children's Habilitative > Sevices > > > > > > Dear Member: > > > > > > This is to notify you that Washington DC has passed a law > effective > > > June 1, 2007, which provides coverage for Children's Habilitative > > > Serices. > > > > > > With the exception of early intervention or school programs, > > > habilitative services means services, including occupational > > therapy, > > > physical therapy, and speech therapy, for the treatment of a > child > > > under the age of 21 with a congenital or genetic birth defect to > > > enhance the child's ability to function. These defects are > > existing > > > at or from birth, including a hereditary defect. The > > > term " congenital or genetic birth defect " includes autism or an > > > autism spectrum disorder and cerebral palsy. > > > > > > These Habilitative services may need to be precertified by Aetna. > > > > > > If you have any questions, please call Member Services at the > toll- > > > free number on your ID card. > > > > > > Sincerely, > > > Aetna > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 15, 2008 Report Share Posted May 15, 2008 I live in good old brook park so definately in NE Ohio.. And according to the letter it is federal legislation.. not state.. Hope that helps! J > > > > > > > > Not sure if everyone else got this from their insurance > companies > > > or > > > > not.. but I got a letter stating the following from Aetna > > yesterday > > > > in the mail. Now why the law was passed last June and we are > > just > > > > not receiving the information is beyond me.. but I know I'm > going > > > to > > > > be appealing some claims that were denied and using this > letter > > as > > > my > > > > rason for why.. > > > > > > > > Take care all! > > > > > > > > J > > > > > > > > Re: New Washington DC legislation - Children's Habilitative > > Sevices > > > > > > > > Dear Member: > > > > > > > > This is to notify you that Washington DC has passed a law > > effective > > > > June 1, 2007, which provides coverage for Children's > Habilitative > > > > Serices. > > > > > > > > With the exception of early intervention or school programs, > > > > habilitative services means services, including occupational > > > therapy, > > > > physical therapy, and speech therapy, for the treatment of a > > child > > > > under the age of 21 with a congenital or genetic birth defect > to > > > > enhance the child's ability to function. These defects are > > > existing > > > > at or from birth, including a hereditary defect. The > > > > term " congenital or genetic birth defect " includes autism or > an > > > > autism spectrum disorder and cerebral palsy. > > > > > > > > These Habilitative services may need to be precertified by > Aetna. > > > > > > > > If you have any questions, please call Member Services at the > > toll- > > > > free number on your ID card. > > > > > > > > Sincerely, > > > > Aetna > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 16, 2008 Report Share Posted May 16, 2008 Where is the federal part? Washington DC has other laws that only apply to DC, gun control etc. > > > > > > > > > > Not sure if everyone else got this from their insurance > > companies > > > > or > > > > > not.. but I got a letter stating the following from Aetna > > > yesterday > > > > > in the mail. Now why the law was passed last June and we are > > > just > > > > > not receiving the information is beyond me.. but I know I'm > > going > > > > to > > > > > be appealing some claims that were denied and using this > > letter > > > as > > > > my > > > > > rason for why.. > > > > > > > > > > Take care all! > > > > > > > > > > J > > > > > > > > > > Re: New Washington DC legislation - Children's Habilitative > > > Sevices > > > > > > > > > > Dear Member: > > > > > > > > > > This is to notify you that Washington DC has passed a law > > > effective > > > > > June 1, 2007, which provides coverage for Children's > > Habilitative > > > > > Serices. > > > > > > > > > > With the exception of early intervention or school programs, > > > > > habilitative services means services, including occupational > > > > therapy, > > > > > physical therapy, and speech therapy, for the treatment of a > > > child > > > > > under the age of 21 with a congenital or genetic birth defect > > to > > > > > enhance the child's ability to function. These defects are > > > > existing > > > > > at or from birth, including a hereditary defect. The > > > > > term " congenital or genetic birth defect " includes autism or > > an > > > > > autism spectrum disorder and cerebral palsy. > > > > > > > > > > These Habilitative services may need to be precertified by > > Aetna. > > > > > > > > > > If you have any questions, please call Member Services at the > > > toll- > > > > > free number on your ID card. > > > > > > > > > > Sincerely, > > > > > Aetna > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2009 Report Share Posted April 19, 2009 I don't know what they are requiring. They turned me down initially due to no labs, then when they got them they turned it down anyways. I added a couple more bullet points for loss of muscle mass and fat redistribution. Hopefully this will be all I need to do. They let me get a vial while they were deciding so I'm not out and have time to get this straightened out. If they turn it down again I can appeal directly to Medicare who should approve it since I've already been on it. Thanks! K. Woolf -------------------------------------------- , Do you inject every week or every 2 weeks? You should be low by the day before your next injection, or, even better, the morning right before it. Would your doctor be willing to order you a requisition form you could use when you're at your lowest level of testosterone? I've also ordered requisition forms for myself when I wanted to test different times during the week. ~Xian Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2009 Report Share Posted April 19, 2009 > > I don't know what they are requiring. They turned me down initially due to no labs, then when they got them they turned it down anyways. I added a couple more bullet points for loss of muscle mass and fat redistribution. Hopefully this will be all I need to do. They let me get a vial while they were deciding so I'm not out and have time to get this straightened out. If they turn it down again I can appeal directly to Medicare who should approve it since I've already been on it. > > Thanks! > > K. Woolf > -------------------------------------------- > , > > Do you inject every week or every 2 weeks? You should be low by the day before your next injection, or, even better, the morning right before it. Would your doctor be willing to order you a requisition form you could use when you're at your lowest level of testosterone? > I've also ordered requisition forms for myself when I wanted to test different times during the week. > > ~Xian > Hi Xian, No I inject 40mg 2x a week. I did my labs before an injection that week. It's all under Medicare, I just switched add-on insurance companies this year. I've included a copy of last year's approval letter with my appeal...so hopefully.. Thanks Quote Link to comment Share on other sites More sharing options...
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