Need help with an insurance appeal for OT

[Guest guest]

I have always heard the horror stories about dealing with insurance

companies who have denied coverage for dyspraxia/apraxia. I always

sent up thankful prayers that we had a good company who has covered

everything we have ever asked for and I bragged on them routinely.

Well, I'm not bragging now!

My son has been getting OT since November. I just got a letter from

our insurance denying his OT from here on out claiming that they

don't cover Learning Disabilities. So now I am facing an appeals

process. I am getting all of 's doctors to write letters on

his behalf but would also really like to include some good technical

definitions of global dyspraxia and Limb apraxia and some studies

which prove the benefit of OT for those who have limb apraxia. I am

having a hard time coming up with a decent definition that doesn't

include the word " developmental " , which I understand is a red flag

for all insurance companies.

Has anyone out there faced this one before? I would be grateful for

some advice!

[Guest guest]

Hi :

The problem is not with which code you use, but how your insurance

considers it.

The codes for motor disorder and language disorder unfortunately have

315 prefixes, which are the same as learning disorders. Using 781.30

may help, but the insurance companies have sophisticated software

that can label anything as " developmental " if they want to. And they

get better at it by the day - as they don't have to prove they are

colluding to the government, but g-d forbid two doctors have lunch

together and you get charged with monopolistic practices...end of my

venting.

The answer is to make things worse than they really are - and make it

sound that he fell on his head/arm/etc., thereby causing the

functional problem. THAT they will buy into, as they have guidelines

for REhabilitation, but not for habilitation of a non-injury

dysfunction.

I hope that helps..

Larry Laveman, MD

Consultant, CHERAB

http://www.apraxia.cc

> I have always heard the horror stories about dealing with insurance

> companies who have denied coverage for dyspraxia/apraxia. I always

> sent up thankful prayers that we had a good company who has covered

> everything we have ever asked for and I bragged on them routinely.

> Well, I'm not bragging now!

>

> My son has been getting OT since November. I just got a letter

from

> our insurance denying his OT from here on out claiming that they

> don't cover Learning Disabilities. So now I am facing an appeals

> process. I am getting all of 's doctors to write letters on

> his behalf but would also really like to include some good

technical

> definitions of global dyspraxia and Limb apraxia and some studies

> which prove the benefit of OT for those who have limb apraxia. I

am

> having a hard time coming up with a decent definition that doesn't

> include the word " developmental " , which I understand is a red flag

> for all insurance companies.

>

> Has anyone out there faced this one before? I would be grateful

for

> some advice!

>

>