Update to: Insurance denied him additional therapy (got reasons today)

[Guest guest]

Well, I'm finally getting an answer at least. Blue Cross sent a letter with

reason for denial. As a history, he was also getting feeding therapy, and when

they asked for additional services, they requested it as feeding, since BCBS

might also deny if we were getting feeding all along and then switched to

speech.

The letter said that they found no medical evidence for additional services,

because

1> On his 3 yr checkup, the dr's notes read 'patient is doing well, no parental

concerns'. 'Apraxia was noted on examination, but detail was not given'

2> In Oct '08, patient was seen by (neurologist), who noted an articulation

delay, did not recommend speech services.

3> In May '09, patient was seen by (ear nose throat dr) who stated that speech

was " normal " .

If you'd like to appeal, please call or send additional info, or have a dr do so

on your behalf, to number sent with enclosure. They never sent the enclosure.

This is so freakin' typical!!

I called the dr today and asked him to appeal. I wrote a 2 page letter to him

(with permission to forward to insurance), stating that

1> at his 3 yr checkup, I was (and still am) concerned about his speech, but as

it was being treated at school and privately, I expressed no ADDITIONAL concern.

2> The neuro was aware he was getting speech at the July visit, so why would she

re-recommend in October if she knew he was getting services.

3> The ENT saw him when he had an ear infection, and probably wasn't talking

much. Without her giving him a speech eval, she has no way of stating his speech

is " normal " .

4> He still gags on certain food textures, and that is why we continued therapy.

5> Without continued therapy, there is evidence that children with apraxia could

regress.

6> a request that the pediatrician states that being pedi's patient, the pedi

should be more qualified than a dr reading notes to determine medical necessity

for services.

Etc, etc. I can't believe that they found a way to twist the notes to make him

sound like a child with a mild articulation delay instead of a child with

apraxia. Apparently, they completely overlooked evals from Speech Therapists

both privately and through a hospital full of references about his inability to

properly speak. Aren't they more qualified than an ear/nose/throat dr? Or

perhaps, more qualified than the pediatrician who sent us to the speech

therapist because they can do more for my son than the pediatrician himself?

I considered not appealing originally, on the grounds that by the time they

responded in 60 more days, it would be mid-december, and new services start in

January. Now, I'm worried that even though the contract calls for an automatic

30 visits, that they're going to deny even those based on what they seem to

think is perfect language ability on his part.

I would love more than anything to pull him off the fish oils and drive him to

the medical director who made this decision, and ask them to chat for 10 minutes

so he can really hear the voice of the child whose life he's attempting to ruin.

But I know that it would hurt my son more than anything to remove him from the

oils. And yet, I would be willing to do it if Horizon offered to do another

speech eval on him. Everything I can offer them now comes from 2008. I never

received a copy of his Jan '09 EI exit eval. (I've asked a few times). Something

current to know where he stands would help.

Thanks for listening to my ongoing gripe, and for your responses.

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