Re: Letter requesting additional therapy

[Guest guest]

I have heard (I think I read it in " Late Talker " ) that with some insurance

companies, you want to avoid the word " therapy " and say " treatment " instead.

Jill B.

[ ] Letter requesting additional therapy

I need to send this letter via USPS Certified Return Receipt ASAP

(by 4pm today). Does it look okay? I am not hopeful as I have never

had an HMO grant anything extra no matter how sincere the need but I

can dream!

" To Whom It May Concern:

My son, , who is thirty-three months old, has been diagnosed

with dysarthria 784.5 by his current speech and language

pathologist. He was diagnosed with Oral Dyspraxia 784.69 by his

previous speech and language therapist. (See enclosed information).

His primary diagnosis is Poland's Syndrome. To remediate this

condition, has been receiving swallowing treatments (the

apraxia affects his oral motor musculature as well as his fine and

gross motor functions). His progress has been good, and all

concerned believe continued therapy is crucial to overcome this

condition.

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. Right now can only say three

words (mama, dada, and nana). He is non-verbal. 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.

Since apraxia is a medical condition and not a developmental delay

or disorder, and since speech and occupational therapy are medically

necessary, I request an additional 20 therapy visits followed by a

reevaluation to assess progress. Thank you for your consideration.

Sincerely, "

[Guest guest]

You may want to argue the insurance company by telling them it is a medical

necessity versus using educational terminology. We had this problem and I

got my husband's human resource department involved in writing a letter to

the insurance company stating reasons for medical necessity and asking the

audiologist and other professionals to use medical terms in their reports.

Good luck!

Joanne

P.S. Only 10% fight the insurance companies on their denials! 100% win

their cases after a long drawn out fight! Don't give up . . .

They denied us on the code for Apraxia 784.69 claiming its developmental

which we all know it's NOT, but they approved the therapy for the code for

Language processing disorder 388.43.

A great code to use if you have a child with apraxia 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.

We have 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).

all the best,

Joanne Mulholland

[Guest guest]

Do you have a letter of medical necessity from your pediatrician or

developmental pediatrician? (It could say nearly the same thing). This

will strengthen your request more than a parental request for services.

[ ] Letter requesting additional therapy

I need to send this letter via USPS Certified Return Receipt ASAP

(by 4pm today). Does it look okay? I am not hopeful as I have never

had an HMO grant anything extra no matter how sincere the need but I

can dream!

" To Whom It May Concern:

My son, , who is thirty-three months old, has been diagnosed

with dysarthria 784.5 by his current speech and language

pathologist. He was diagnosed with Oral Dyspraxia 784.69 by his

previous speech and language therapist. (See enclosed information).

His primary diagnosis is Poland's Syndrome. To remediate this

condition, has been receiving swallowing treatments (the

apraxia affects his oral motor musculature as well as his fine and

gross motor functions). His progress has been good, and all

concerned believe continued therapy is crucial to overcome this

condition.

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. Right now can only say three

words (mama, dada, and nana). He is non-verbal. 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.

Since apraxia is a medical condition and not a developmental delay

or disorder, and since speech and occupational therapy are medically

necessary, I request an additional 20 therapy visits followed by a

reevaluation to assess progress. Thank you for your consideration.

Sincerely, "

[Guest guest]

I second this plan - and I avoid any developmental/educational

language in both progress reports and requests for coverage - it

doesn't help.

Also, before bringing in your HR person, it's important to see HOW

it is managed at each individual company. We've done this

successfully a few times, but now we understand that because of age

differences, there is more out of pocket for the company. ie - they

wouldn't want to authorize this.

Good luck - M

>

>

> You may want to argue the insurance company by telling them it is

a medical

> necessity versus using educational terminology. We had this

problem and I

> got my husband's human resource department involved in writing a

letter to

> the insurance company stating reasons for medical necessity and

asking the

> audiologist and other professionals to use medical terms in their

reports.

>

> Good luck!

> Joanne

>

> P.S. Only 10% fight the insurance companies on their denials!

100% win

> their cases after a long drawn out fight! Don't give up . . .

>

> They denied us on the code for Apraxia 784.69 claiming its

developmental

> which we all know it's NOT, but they approved the therapy for the

code for

> Language processing disorder 388.43.

>

> A great code to use if you have a child with apraxia 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.

>

> We have 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).

>

> all the best,

> Joanne Mulholland

>

[Guest guest]

I'm not seriously suggesting this, but I wonder what would happen if we all

started to submit

codes for neurological damage due to heavy metal poisoning?

Peace,

Kathy E.