Health Care Denial

[rwilk]

DD was assessed for motor delays.  She struggles with movement, balance, and coordination, and has since she was a baby.  She was in help me grow in Ohio for about a year, then she caught up a bit.  At 4, she's showing clear delays again.  

 

Insurance denied PT treatment because her condition does not meet medical necessity because it "is not caused by illness, injury, surgery, or birth defect." Which is true.  But the doctors think it is necessary.  She can't coordinate to dress herself (not even a shirt or socks let alone buttons/zippers), can't hop, can't potty train....the list goes on.  

 

I'm not really sure where to go from here.  We are having her assessed by the district for an IEP as well, but they don't offer services if it's only physical.  

 

I'd really appreciate any thoughts you might have.  

[GAPeachie]

Appeal.  This is a common tactic I've seen.  Make sure the report addresses ADLs (Activities of Daily Living.)  

Edited February 23, 2016 by GAPeachie

[Ravin]

Yup. Appeal. 

[mtomom]

Do you have a copy of the policy? Some policies provide habilitative PT for the issues you mentioned, but also if the proper skills simply failed to develop. If your policy is worded like that, I think you have a definite appeal. If the policy excludes developmental issues, that's more problematic. You need to know what it actually says.

 

Our policy excludes all developmental related issues except autism. They only cover that because the state makes them. I don't think situations like this are uncommon unfortunately. Our options for speech therapy for my son were school system or private pay. If it is excluded by your policy, you could ask the doctor if there are any programs that might cover issues like hers.

Edited February 23, 2016 by mtomom

[Crimson Wife]

Appeal, but be aware that policies excluding rehab services (speech, occupational, & physical) when the issue is developmental rather than illness/injury are legal in many states. When the delays are secondary to autism, the state autism mandate forces insurers to cover rehab services. But for kids not on the spectrum, they are often unfortunately S.O.L.  :thumbdown:

[PeterPan]

‎education.ohio.gov/getattachment/Topics/Other-Resources/Scholarships/Special-Needs-Scholarship/Jon-Peterson-Scholarship-For-Providers/JPSNCategoryAmounts.pdf.aspx

 

Don't sign things till you understand what you're doing.  You don't want to sign an eval form that does not include all the categories you need eval'ed.  As a hs'er, you're able to apply for the Jon Peterson scholarship (in Ohio) BEFORE you ahve an IEP.  The window is getting ready to open.  You apply, make your formal written request for the evals, and the ps is FORCED to do the evals to determine need.  I *think* you are covered during this age 4.  Check the law.  

 

If a dc cannot dress themselves or do age-appropriate things, then their adaptive living issues are affecting their ability to get to school and receive an education.  There is adaptive living on the evaluation planning form.  

 

Are they giving her a label like DCD or CP or something?  Look up that diagnosis and compare it to the legal definitions for the terms in the scholarship tiers.  Those are legal terms.  So where it says OHI-Minor, you look that up and see if your dd's diagnosis (whatever it is) fits that.  If it affects her ability to access her education, it HAS to be covered.  

 

You're probably going to need to call ODE and call people and talk with them.  It takes a while to get replies, so don't delay.  Calling ODE definitely, definitely helps, so don't be afraid to call.  

Edited February 23, 2016 by OhElizabeth

[rwilk]

Thank you all so much!

 

I just assumed because they said no, it was well, no.  The phrase habilitative services is completely new to me, and has been really helpful in guiding me in searching policy documents and state laws.

 

OhElizabeth, sadly we are no longer in Ohio, we are temporarily in California.  We might be back in Ohio starting in August, so that's really helpful information for then. The doctors seem fairly unsure as to WHY she's having these issues---we don't have a clear diagnosis.  It seems like her vestibular system didn't develop properly, her muscles don't respond the way other children's seem to, and as a result she is EXTREMELY cautious in movement, causing snowballing sorts of delays. It would be nice if there was a clear diagnosis or reason for all her struggles. 

 

One of my biggest frustrations is that we have to move every year or 2 for my husband's career.  Insurance changes, state laws change, and it feels like we spend our whole time in a new state getting services in place, and then we have to move and fight all over again.

[prairiewindmomma]

We've gone through/are going through a similar thing.

 

We are cash pay for OT.  Most pediatric OT facilities are full of families in the same boat.  They've been very understanding in our need to stretch out sessions with a lot of homework for us, and have tried very hard to let us be able to get our dc as much therapy as they can.  I'd also work all of your resources---today we are checking out a nonprofit facility that works out to $35/therapy hour--much more reasonable than the $100-150 therapy hour that we typically pay.

 

The SN advocacy group for your city/state can be very helpful! Be sure to check with them to understand all of the opportunities in your community as well as your legal rights. 

[Crimson Wife]

 

OhElizabeth, sadly we are no longer in Ohio, we are temporarily in California.  We might be back in Ohio starting in August, so that's really helpful information for then. The doctors seem fairly unsure as to WHY she's having these issues---we don't have a clear diagnosis.  It seems like her vestibular system didn't develop properly, her muscles don't respond the way other children's seem to, and as a result she is EXTREMELY cautious in movement, causing snowballing sorts of delays. It would be nice if there was a clear diagnosis or reason for all her struggles.

 

I would request an eval through the Regional Center. It's free, and if they do accept your child as a client, you will be entitled to Medi-Cal as secondary insurance for your child. Medi-Cal pays for OT, PT, speech, Applied Behavioral Analysis, etc. either 100% (if your primary excludes them from coverage) or the co-pays and deductibles (this is what my DD has).

[GoVanGogh]

Look into your state law, as some states mandate that insurance companies provide a certain service until a specific age. (Ex: In our state, insurance companies are required to cover habilitative therapies for non-injury issues until age seven, I think.)

 

Our son has cp, so his therapies are considered habilitative instead of rehabilitative, which angers me to no end. If he were to fall off a bike and suffer a head injury, therapy would be covered. But because he suffered a stroke, he is out of luck. Our son gets more therapy coverage because of autism than he does cerebral palsy. It makes no sense.

 

Appeal, appeal, appeal... In our state, we have the right to appeal three times. We often do appeal all three times before we get coverage. After the third time, our state regulations allow that we can take our appeal to the state attorney general. We once notified the insurance company, after three lost appeals, that we were taking the appeal to the state level. They called us an hour later to notify us that they had reconsidered and would cover the therapies. Persistence pays off.

 

We have had an appeal ongoing for the past six months for speech therapy. We had all of our son's doctors write a letter of medical necessity, explaining HOW his disability was affecting him and WHY he needed speech therapy. Our speech therapist then did a re-evaluation, showing DS's improvement during that time period, along with a detail letter of how his speech disorder affected his ability to live an independent life and how therapy was helping. (During this time period, I had a life threatening medical emergency while home alone with DS, age 14, and DS was unable to communicate with DH over the phone or with first responders and we outlined that, as well.) We submitted probably 20 pages of documentation. Yes, it was time consuming, we were approved.

 

We have insurance changes every year or two. It makes it crazy difficult, as it seems we have to start over again once we have jumped through all the hoops of one insurance company.

[laundrycrisis]

We were able to get services covered with a diagnosis of low muscle tone from a pediatrician.

[AimeeM]

Appeal, but be aware that policies excluding rehab services (speech, occupational, & physical) when the issue is developmental rather than illness/injury are legal in many states. When the delays are secondary to autism, the state autism mandate forces insurers to cover rehab services. But for kids not on the spectrum, they are often unfortunately S.O.L.  :thumbdown:

This.

The Marvelous Flying Marco (DS3) had severe speech delays and needed OT. We had to pay out of pocket when he aged out of the city services - insurance wouldn't cover it, regardless of how much he needed the therapies.

 

However, they were happy to cover speech for DS6, who didn't need it, because he had a dental prosthetic that impacted his speech (except that there was nothing ST could do for him - his speech would improve when the prosthetic was removed, and did). Whatever :P

 

 

However, DS3 is now undergoing autism evals (loooong process) and if that comes back with anything on the spectrum, insurance will suddenly cover everything.