Re: Private Insurance coverage for Apraxia

June 17, 2009

My daughter, age 6, has been in Speech since age 3 but we only started claiming

on insurance last year - and it's all been denied/appealed/denied/medical

review/denied/appealed - etc...

The best advice I have seen on this is at the following website - here's the

link -

http://www.speechville.com/diagnosis-destinations/apraxia/insurance.html

One of the main things I learned was not to use a code that involves the word

" developmental " , and also to be sure to specify that the speech therapy is

" rehabilitative " .

Here is parts of the information from that site:

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 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.

Website at which to Research Codes:

The code for apraxia is under ICD-9 Codes. Insurance Code Website

Also see Dr. Marilyn Agin's advice, " Insurance: Dealing with the Big Guys, " at

Children's Apraxia Net and read message number 263.

Denials and Appeals: If you are denied coverage for your child's speech and

language therapy, always ask for the denial in writing and appeal the decision

using the proper appeal procedure within your insurance company. Insurance

companies count on consumers not appealing decisions. And the fact is that most

people don't. All along the way, document your phone calls to the insurance

company and also be sure to note whom you spoke with (first and last names) and

what date you spoke to them. Keep brief notes about what each person told you.

Documentation can be helpful for an appeal. In some states, even if (or

regardless whether) you have exhausted appeal procedures within your insurance

company, you can appeal to your state's insurance commission (and some state

insurance commissions now allow the filing of complaints via the Web).

The Stroke Caregiver's Handbook advises that consumers not pay medical bills

until you have exhausted the insurance appeals process: " One major insurance

provider admitted that 98% of all judgments are reversed when appealed. Once you

pay $1 of a bill, you are claiming full responsibility for that bill, and once

you pay a doctor or hospital yourself, you will spend years trying to get that

money back from the insurance company, if at all. "

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.

June 19, 2009

Hi ,

My daughter has diagnosis of Mixed Expressive/ Receptive Language Disorder under

the diagnosis code ICD-9 315.32.

How can I find if Blue Cross- Blue Shield PPO can paid for her therapist??

The Insurance denied to pay.

Please I need help , if you can give me any information I'll appreciate.

Thanks,

Teddy

From: socialwkr@... <socialwkr@...>

Subject: [ ] Re: Private Insurance coverage for Apraxia

Date: Wednesday, June 17, 2009, 5:14 PM

My daughter, age 6, has been in Speech since age 3 but we only started claiming

on insurance last year - and it's all been denied/appealed/ denied/medical

review/denied/ appealed - etc...

The best advice I have seen on this is at the following website - here's the

link -

http://www.speechvi lle.com/diagnosi s-destinations/ apraxia/insuranc e.html