Re: How can they deny him speech?

[Guest guest]

I live in NY and we also have BC/BS Preferred PPO. Our insurance does

cover therapy. Did you try calling the insurance company yourself?

Maybe this speech therapist is mistaken?

>

> I just got a call from the SLP who evaluated my son last week and

> diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> insurance won't cover his speech therapy. We have Blue Cross/ Blue

> Shield PPO. I don't think the coverage gets much better than that! The

> SLP said we could pay out of pocket at $120 per week. We would be

> driving an hour each way to speech, so she suggested a one hour

> session, once per week. I have the Kaufman Workout Book and Cards at

> home...but I don't feel like I am doing him a lot of justice working

> with them. I am so frustrated and unsure of how to help our. Our local

> school district is difficult to work with and has some really weird

> loopholes you have to jump through to get speech. I honestly don't

> trust them with him. Please help...should I take him to see

> Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

>

[Guest guest]

Good to know that they are covering speech for other children with

Apraxia. We have been told by the insurance company that it is not

medically necessary. Even though he is 2 years behond on expressive

language and less than 10% intelligible speech...

My mom works in the insurance " world " so we are going to call them

together today to find out about the appeal process. In the meantime -

my hubby agrees we must pay out of pocket to get him the help he

needs, even though that will be a huge cost each month. We are also

considering a trip to see Kaufman to find out more about how to

work with him at home.

I am determined not to let an insurance company dictate whether my son

will ever speak or not. That is silly!

Thanks to you all for letting me vent my frustrations!

Leah

> >

> > I just got a call from the SLP who evaluated my son last week and

> > diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> > insurance won't cover his speech therapy. We have Blue Cross/ Blue

> > Shield PPO. I don't think the coverage gets much better than that! The

> > SLP said we could pay out of pocket at $120 per week. We would be

> > driving an hour each way to speech, so she suggested a one hour

> > session, once per week. I have the Kaufman Workout Book and Cards at

> > home...but I don't feel like I am doing him a lot of justice working

> > with them. I am so frustrated and unsure of how to help our. Our local

> > school district is difficult to work with and has some really weird

> > loopholes you have to jump through to get speech. I honestly don't

> > trust them with him. Please help...should I take him to see

> > Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

> >

>

[Guest guest]

>

> I just got a call from the SLP who evaluated my son last week and

> diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> insurance won't cover his speech therapy. We have Blue Cross/ Blue

> Shield PPO. I don't think the coverage gets much better than that! The

> SLP said we could pay out of pocket at $120 per week. We would be

> driving an hour each way to speech, so she suggested a one hour

> session, once per week. I have the Kaufman Workout Book and Cards at

> home...but I don't feel like I am doing him a lot of justice working

> with them. I am so frustrated and unsure of how to help our. Our local

> school district is difficult to work with and has some really weird

> loopholes you have to jump through to get speech. I honestly don't

> trust them with him. Please help...should I take him to see

> Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

>

We were in a similar situation with BC/BS PPO, except in NJ. After

several appeals and the usual agonizing " well that's what the benefits

say " , we were able to get coverage by getting a PDD-NOS diagnosis.

Don't know if Cal. works the same, but it may be worth a try, good

luck....

[Guest guest]

From what I understand it's all how the script for s/t is worded. Our insurance

does not cover speech therapy for a delay but apraxia is not a delay it is a

nuerological disorder. YOu should find a speech therapist who has plenty of

experience with apraxia and then she or he should know how to get the coverage.

My insurance does not cover s/t but we get coverage if the proper codes are

used. Ex. oral motor weakness, feeding issues, also your nuero or dr. who wrote

the script needs to use the right codes. From what I understand the script

should never say developmental delay. Also, a child with apraxia needs more s/t

then once a week. Take what you can get from the school just make sure it is the

right kind of therapy. My 2 1/2 year old gets therapy 5xs a week. Good luck.

-------------- Original message from " Leah " <kaiserfamily4@...>:

--------------

I just got a call from the SLP who evaluated my son last week and

diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

insurance won't cover his speech therapy. We have Blue Cross/ Blue

Shield PPO. I don't think the coverage gets much better than that! The

SLP said we could pay out of pocket at $120 per week. We would be

driving an hour each way to speech, so she suggested a one hour

session, once per week. I have the Kaufman Workout Book and Cards at

home...but I don't feel like I am doing him a lot of justice working

with them. I am so frustrated and unsure of how to help our. Our local

school district is difficult to work with and has some really weird

loopholes you have to jump through to get speech. I honestly don't

trust them with him. Please help...should I take him to see

Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

[Guest guest]

Here are some archived messages about insurance for speech therapy.

Make sure they are using the correct codes for insurance--stay away

from developmental codes. I had BCBS HMO and didn't have any trouble

getting speech covered by insurance. So call the SLP and ask her

which codes she used for insurance and ask her to use the different

ones mentioned below by Dr. Agin.

Good luck,

Tina

/message/8923

Archive from

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

-Dear Kari, I wanted to respond to your insurance code question for

apraxia. In the ICD 9 medical code book, #315.4 is Dyspraxia Syndrome.

The confusion is that is that many of the #315 codes are

developmental, but not this one. #784.69 is probably the safer code to

use in that it comes from the section where the codes are neurologic.

I am also adding to this a previous post (#263) which further

elucidates this:

One of the forces that most of our families with apraxic children

have had to deal at some time or another is the medical insurers. If a

medical professional or speech pathologist writes a report or a

bill for submssion to the insurance company, here are some

important tenets to follow:

-Oral/verbal apraxia is a neurologic disorder so never use the word

developmental or a code that is " developmental " in the report or

on the bill. -Useful ICD codes for Apraxia of Speech are #315.40 or

#781.3. The latter code is also one used for Hypotonia, Sensorimotor

Integraton Disorder, and Coordinaton disorder, which may be associated

with apraxia of speech.

-If there is an associated expressive language disorder with the

apraxia, which is commonly the case, use #784.6 which is " other

symbolic dysfunction. " If #315.3, 315.31, 315.39, or 315.9 are used,

these are developmental codes and may not be reimbursed.

Often the insurance co. will ask your doctor to write a Letter of

Medical Necessity of Letter of Predetermination. This needs to state

the appropriate diagnosis and code number, state that the

diagnosis(ses) have a neurologic basis and are not developmental, and

intensive treatment by qualified, experienced speech and

occupational therapists is required. Often you need to state the

specialized nature of the therapy (PROMPT, oromotor, sensory

integration, etc.) and explain why your therapist is more qualified

than the one who is " in network " for provider. Have your therapists

state their specialized credentials and certifications.

-Define apraxia as a speech disorder where the brain signals that go

to the muscles and structures of the speech mechanism are

disrupted.

-Without therapy, children do not outgrow apraxia of speech. Speech

therapy is needed at least 4x week by experienced oral motor speech

therapists. Without this therapy, prognosis for improvement is poor.

-The provider may only provide therapy for 2 months or 6 months

of therapy. Accept it and reapply with new goals set by your speech

pathologist.

Don't be discouraged by a rejection. That's what they want, They

want to wear you down, but don't let them. This is your child and

you have to continue the fight and go to the top person in the plan.

If they tell you this is a preexisting condition, this is absolutely

absurd when talking about a child.

Be advised though, that some insurers are better than others. Some

will never offer speech services unless your child has had a stroke or

accident. (What a horrible thought). If you have a choice of insurers,

make sure you choose one wisely. Look at the benefits before you sign

up.

Good luck!

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

http://www.apraxia.cc

=============

Archive from

Larry Laveman, MD

Medical Consultant, CHERAB

Hi Kari:

The code 315.4 generally refers to motor delays, and indicates a

developmental origen (the 315 prefix is used for developmental and

learning disorders).

Codes beginning with 7 generally refer to signs and symptoms, and

most doctors and therapists are advised by their coding gurus to

avoid them, as they can sometimes cause reduced reimbursement (we all

want to get paid fairly...).

Some insurances may not recognize the 784.69 code, and reject the

claim on this basis. I am cautious in my practice to always give

multiple dx codes, describing the full symptom complex of the child.

Larry Laveman, MD

Medical Consultant, CHERAB

http://www.apraxia.cc

archived message about insurance

/message/42108

>

> From what I understand it's all how the script for s/t is worded.

Our insurance does not cover speech therapy for a delay but apraxia

is not a delay it is a nuerological disorder. YOu should find a

speech therapist who has plenty of experience with apraxia and then

she or he should know how to get the coverage. My insurance does not

cover s/t but we get coverage if the proper codes are used. Ex. oral

motor weakness, feeding issues, also your nuero or dr. who wrote the

script needs to use the right codes. From what I understand the

script should never say developmental delay. Also, a child with

apraxia needs more s/t then once a week. Take what you can get from

the school just make sure it is the right kind of therapy. My 2 1/2

year old gets therapy 5xs a week. Good luck.

> -------------- Original message from " Leah " <kaiserfamily4@...>: ---

-----------

>

> I just got a call from the SLP who evaluated my son last week and

> diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> insurance won't cover his speech therapy. We have Blue Cross/ Blue

> Shield PPO. I don't think the coverage gets much better than that!

The

> SLP said we could pay out of pocket at $120 per week. We would be

> driving an hour each way to speech, so she suggested a one hour

> session, once per week. I have the Kaufman Workout Book and Cards at

> home...but I don't feel like I am doing him a lot of justice working

> with them. I am so frustrated and unsure of how to help our. Our

local

> school district is difficult to work with and has some really weird

> loopholes you have to jump through to get speech. I honestly don't

> trust them with him. Please help...should I take him to see

> Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

>

>

>

>

>

>

[Guest guest]

You need to find out how your SLP is billing your insurance company.

Some terminologies are not accepted as medically necessary by ins.

companies. My insurance does cover apraxia as it is termed as a

neurologically based disorder not developmental. If developmental is

anywhere on the billing, chances are your insurance will reject it.

Hope that helps.

> > >

> > > I just got a call from the SLP who evaluated my son last week and

> > > diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> > > insurance won't cover his speech therapy. We have Blue Cross/ Blue

> > > Shield PPO. I don't think the coverage gets much better than

that! The

> > > SLP said we could pay out of pocket at $120 per week. We would be

> > > driving an hour each way to speech, so she suggested a one hour

> > > session, once per week. I have the Kaufman Workout Book and Cards at

> > > home...but I don't feel like I am doing him a lot of justice working

> > > with them. I am so frustrated and unsure of how to help our. Our

local

> > > school district is difficult to work with and has some really weird

> > > loopholes you have to jump through to get speech. I honestly don't

> > > trust them with him. Please help...should I take him to see

> > > Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

> > >

> >

>

[Guest guest]

Grhhhhh!! I've been dealing with this off/on for a number of years for

my dd on Spectrum and just didnt have the time to mess with it, so we

sucked up and paid privately. We too are an hour from therapy and our

schedule was grueling for awhile.

BUT I just want to say APPEAL! Long ago I worked in managed care as a

case manager and the folks who took the time to appeal, often won.

Managed care was sooo bad and so many entities went belly up long ago

that a lot of the therapy groups in our area dont take ins at all.

They provide you with the claim form and codes and you submit.

Grhhhh.. just more work. But I did want to say, APPEAL.. it's often

the only way. I'm on another list for Spectrum kids with Kaiser ins

and someone just posted that their Appeal was reviewed by IMR (Ind Med

Review ) and Kaiser's denial was overturned. Her child will now get

the ST, OT and ABA he desperately needs. I've been thru the ringer

with our school system at times but ultimately we got some pretty good

services. Now (in elementary) the ST pretty much sucks - too much

group but it's ok. If you want to bounce ideas off me as to getting

better services thru the school - feel free to shout.. You can PM me

altho I'm sure many here have had tremendous experiences they can

share. I'm in N. CA. The beauty for your child with his dx would be

to get both in place as he's so young.... Good luck!

Leigh

>

> I just got a call from the SLP who evaluated my son last week and

> diagnosed as mod-severe Apraxia of Speech (age 3 1/2). She said the

> insurance won't cover his speech therapy. We have Blue Cross/ Blue

> Shield PPO. I don't think the coverage gets much better than that! The

> SLP said we could pay out of pocket at $120 per week. We would be

> driving an hour each way to speech, so she suggested a one hour

> session, once per week. I have the Kaufman Workout Book and Cards at

> home...but I don't feel like I am doing him a lot of justice working

> with them. I am so frustrated and unsure of how to help our. Our local

> school district is difficult to work with and has some really weird

> loopholes you have to jump through to get speech. I honestly don't

> trust them with him. Please help...should I take him to see

> Kaufman? I live in Southern CA...what is a mom to do? Help Please!!!

>