Guest guest Posted May 20, 2008 Report Share Posted May 20, 2008 I feel your pain - I remember arguing with the insurance company about physical therapy and it was the same thing - since he was born with Down syndrome and needed PT it wasn't covered but if he feel off bike or got hit by a bus and need PT it was 100% covered! Ugh!! Good luck!!mom to 10 yrs Ds and Hannah 9 yrs - Fort WayneMy insurance company that I pay over $700 monthly in premiums is refusing to pay for a voice evaluation to determine if my daughter will ever be able to talk. They told me that had she had a stroke or smoked and lost her abilitly to talk, they would cover it. To me that is unfair as my daughter was born with a very rare chromosome abnormality. She didn't ask not to be able to talk. Unlike smokers who choose to smoke and put their voice at risk. It's not fair. Any suggestions on how to proceed with this? This is the same insurance company who refused to pay for her DynaVox V so she would be able to communicate with her peers. Sorry but I'm very upset by this. This eval. will cost anywhere from $1000-1500 and we don't have it. Mom to Jezeca, age 5, Trisomy 10q/5p and to Zephany, 23 months, Trisomy 21 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 20, 2008 Report Share Posted May 20, 2008 What is the medical diagnosis for the speech problem? I know that my insurance co won’t pay for speech therapy for Danny if the diagnosis if listed as “Down syndrome’,or ‘developmental delay’, but they do (and are) paying if the diagnosis lists a medical reason for the speech deficit. Check this article out: http://www.speechville.com/diagnosis-destinations/articulation-disorder/insurance-developmental.html Articulation Disorders are " Developmental " . " Developmental delays " are not Covered. One of the most important things to do when applying for insurance coverage of speech and language-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 " a developmental Articulation Disorder " . While the word " developmental " is a common one in speech therapy literature, for many families the use of the word has 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 the phrase " developmental Articulation Disorder " is not the same as " developmental delay, " nor may he or she know that the word " developmental " is used within the academic literature primarily to distinguish the condition from one that is occurring in an adult. The insurance company might also be confusing an " articulation disorder " 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. An articulation disorder is not a " developmental disability, " though it can co-occur, in some children, with a developmental disability. Regardless of whether or not a child is developmentally disabled, in addition to having an articulation disorder, the insurance company should not deny the claim on the basis of the developmental disability, if speech therapy 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 an articulation disorder 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 the speech difficulty is of a severity that it will not " go away " without treatment. Sometimes describing the condition as a neurological disorder seems to help. Review the Pub Med literature for appropriate quotes. http://www.speechville.com/diagnosis-destinations/articulation-disorder/insurance.html Diagnosis Destinations Articulation Disorder Insurance Insurance coverage for speech therapy is often provided but can require some legwork on your part. Duration of treatment: If your policy specifies that therapy is a " short-term " benefit only, then the speech therapist must submit objectives and goals for short-term durations, i.e. two months or so at a time. Toward the end of the two month period, the therapist will submit a report of progress with renewed objectives and goals for the next two months (and so on). Insurance Codes: The insurance paperwork filled out by the speech-language pathologist or pediatrician often requires a code number. Some codes are red flags for denials. A great code to use if you have a child with an articulation disorder, according to the medical experts from Cherab Foundation , is 781.3 which is " lack of muscle coordination /coordination disorder. " This shows a physical diagnosis, which is typically covered, versus a developmental diagnosis, which is typically not covered. Website at which to Research Codes: The code for apraxia is under ICD-9 Codes. Insurance Code Website http://www.speechville.com/diagnosis-destinations/articulation-disorder/articulation.html Diagnosis Destinations Articulation Disorder What are articulation disorders? " Articulation disorders are difficulties with the way sounds are formed and strung together, usually characterized by substituting one sound for another (wabbit for rabbit), omitting a sound (han for hand), and distorting a sound (ship for sip). Articulation disorders constitute the most numerous of all speech disorders. About 3 out of 5 of all speech and language disorders are related to articulatory problems. " From ASHA " Speech Language Disorders & the Speech-Language Pathologist " . Literature about Articulation Disorders Articulation Disorders: Insurance Articulation Disorders: Research Video and Audio Tapes about Articulation Disorders Articulation Disorders on the Internet From: DownSyndromeInfoExchange [mailto:DownSyndromeInfoExchange ] On Behalf Of Tutwiler Sent: Tuesday, May 20, 2008 6:31 PM To: DownSyndromeInfoExchange Subject: RE: [DownSyndromeInfoExchange] Voice Eval. I feel your pain - I remember arguing with the insurance company about physical therapy and it was the same thing - since he was born with Down syndrome and needed PT it wasn't covered but if he feel off bike or got hit by a bus and need PT it was 100% covered! Ugh!! Good luck!! mom to 10 yrs Ds and Hannah 9 yrs - Fort Wayne My insurance company that I pay over $700 monthly in premiums is refusing to pay for a voice evaluation to determine if my daughter will ever be able to talk. They told me that had she had a stroke or smoked and lost her abilitly to talk, they would cover it. To me that is unfair as my daughter was born with a very rare chromosome abnormality. She didn't ask not to be able to talk. Unlike smokers who choose to smoke and put their voice at risk. It's not fair. Any suggestions on how to proceed with this? This is the same insurance company who refused to pay for her DynaVox V so she would be able to communicate with her peers. Sorry but I'm very upset by this. This eval. will cost anywhere from $1000-1500 and we don't have it. Mom to Jezeca, age 5, Trisomy 10q/5p and to Zephany, 23 months, Trisomy 21 Quote Link to comment Share on other sites More sharing options...
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