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Thread: Insurance appeals?

  1. #1
    danellsar is offline INCIIDer - A Community Creator
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    Default Insurance appeals?

    Our insurance denied David's therapy because it's not a covered service. I am appealing it based on his age and the fact that it's for feeding and he's so small.

    Have any of you gotten approval after being denied by insurance? What hoops did you have to jump through?


    Ellen

  2. #2
    anniemc2000 is offline INCIIDer - A Community Creator
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    Default Yes, we always appeal

    That was the advice given to us by my dds case manager from the HMO. She said always appeal a denial, because then it causes them to actually review the case and many times the claim is then accepted. If your ds has any weight gain issues, or health issues relating to eating (reflux, etc) you may want to mention that as well. Good luck!
    Ann

  3. #3
    jeninnc is offline INCIIDer - A Community Creator
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    Funny you posted - I just got my denial today for Ellie's OT. I am appealing using a doctor's letter - hopefully that will work!

  4. #4
    trek is offline INCIIDer - A Community Creator
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    Default

    YES! With older ds, got Grant's ST covered at 50% but it took me a long time. Actually the insurence was/is through DH, and I started with the HR department at his workplace. It is very important to send copies of any test results, Dr prescirptions staing MEDICAL reasons for the therapy.

    I am currently battling over Holt's ST benefits-they have copies of everything,and keep asking for more if they deny, I will fight.

    Goodluck

  5. #5
    angeleena is offline INCIIDer - A Community Creator
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    Default am fighting this right now for ella's private OT

    They said they would cover it, until they figured out it is "neurodevelopmental."
    (nerves!??)
    Isn't the brain /nerves etc part of our body!???

    I have written a 4 page typed letter that might have been a little emotional. I included a photo of my girl and said "This is a photo of the child that you are NOT helping!"

    i sent a copy to the ceo of the hospital where my dh works. he said he is going to contact HR about it.

    I turned them in to the insurance cops in our state....because they are not supposed to be able to deny this, but i guess there are currently loopholes.

    i contacted our state representative, and ironically, he was going to a hearing about making an insurance MANDATE in our state for paying for PDD NOS like any physical illness. He asked us to write a letter or speak in front of a committee....we sent a letter....there is a good chance that this might go somewhere for the kids that get dx'd behind ella....maybe in a few years....but for now, we fight and fight the insurance.

    I will continue to appeal until there are no appeals left.

    She is no longer in private OT because we cannot afford $160 an hour.

    let me know how things go for you. if i get somewhere, i will let you know.
    all i know is that people have told me everywhere "KEEP APPEALING!"

    -angi

  6. #6
    trek is offline INCIIDer - A Community Creator
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    ANGI~ugh, please keep fighting, eventually soemthing will turn in your favor, they may only pay a portion.

    ** I am currently still battling insurance co over Holt's denial. Sending more test results.**

  7. #7
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    mickey2 is offline INCIIDer - A Community Creator
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    Default

    i am the queen of appeals and have always won. i worked in a major insuranace co appeals and grievances for almost 2yrs and learned many tricks. i even got most of my IF/mc stuff covered!! and over 750K in bills for me and ds since 2001. there are many factors but you can always contact your states insurance commisioner for info. hugs

  8. #8
    Laura H1 is offline INCIIDer - A Community Creator
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    Default ALWAYS!!!! (sibs mentioned)

    I too ALWAYS appeal... ?luckily? Christian was born with a brain anomaly (missing 2/3 of corpus callosum; the cabling between the two brain hemispheres that allow the two sides to communicate)... so they RARELY deny his coverage, whereas they routinely deny the other 2 (triplets) the SAME therapies...

    there is a diagnosis code associated with agenesis of corpus callosum, so the therapists have LEARNED to always use this for Christian...

    For the other two boys, we have learned that as long as we begin with a doctor's referral, then have the therapists write up daily progress notes (most do this anyway, except for our latest OT provider and it caused a back log of 4 months worth of denials that we are having to catch up with)... AND a checklist of goals to be accomplished with the therapies... our case manager(s) have always told us as long as those daily progress notes (notes written during each therapy session, not something I have to do), and a copy of the goals checklist ACCOMPANIES the claim, it gets covered!

    (((hugs))) such a pain to navigate the insurance companies.... BUT with persistance you can WIN!!!! Especially if it is a large insurance company such as Aetna, Cigna, United Healthcare, etc...

    I never had to send to the insurance commission, but I'm glad you did... it should help...

    I struggled for two years to get alot of IF coverage... me and several girls in the "IF Waiting Room" would trade our appeal letters, tweak them, and one girl's dh was a lawyer who would review them... it paid off 3 years of treatment, one IVF and MOST of it finally got covered after a two year battle... like you, i did not expect it to get paid off, but i expected my letters and logic to pave the way for future women...

    It pisses me off to read "Policy Bulletins" stating coverage for speech DELAYS, but at the end denying if your child has PDD/NOS or autism... I swear I want to beat them over the head... I ALWAYS wish they would be blessed with a child with PDD/NOS or Autism so that they can see the ridiculousness/hypocrisy in their "Policy Bulletins"...

    I also get impowerment from READING/SEARCHING through the insurance company "Policy Bulletins"... go to their site, do a search on say, "Auditory Integration Training" (one of the latest things I would like to get covered), and use their own arguments for getting it covered and leaving out any reference to specific exclusions...

    and LASTLY... if your dh works for a hospital it is HIGHLY likely the hospital purchased riders to get normally excluded things covered...

    for examply, dh worked for one of the LARGEST national banks, and the insurance company has a dedicated staff to work with just the employees and their cases... do you know what I found out after fighting the company for THREE years of getting my preemie boys coverage???? THEY HAVE A DEVELOPMENTAL DELAY POLICY RIDER!!!!! Normally excluded for Aetna policy holders, Bank Of America has a special rider to have therapies covered IF our child is proven to have developmental delays up to the age of SEVEN!!!!

    I just found this out in November!!!! ARGH!

    anyway, it pays to find a sympathetic case manager... i'm VERY non-emotional with her... I specifically purge my anger after a denial, wait a day, and then call her "asking for her help"...

    (((hugs))) I REALLY think you can get this covered... especially if you mention your ds gags/chokes while eating and presents this as possibly life threatening... feel free to say you have a friend who's son has been to the hospital for choking/passing out/ambulance called, and has learned the heimlich and used it a few times and that after following a feeding therapy program by a qualified (OT, SLP, etc.) he was able to progress, gain the appropriate weight, get ill less, and bottom line SAVE HIS LIFE...

    hang in there... Laura

  9. #9
    Laura H1 is offline INCIIDer - A Community Creator
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    Default Posting again... I'm someone who NEVER takes no for

    an answer... if my request is reasonable (coverage for feeding therapy in your case is COMPLETE reasonable), then I would NEVER take NO... I would appeal to the end... Insurance companies do NOT like to go to the end...

    If they go to the very end, they risk their policies being changed for EVERYONE... so for the sake of saving money and HOPING others will not appeal, they deny first, and then grease the squeaky wheels...

    go girl!!!!

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