Insurance Coverage Tips For Speech And Other Special Needs Therapies

 “Insurance battles are fought and won every day but you have to be persistent. What does their policy state as far speech therapy? Can you tell me the reason for denial?  One of the most important things to do when applying for insurance coverage of apraxia-related therapy is to ensure that the evaluator  does not use the word “developmental” or “childhood” in his or her report, as in” Childhood Apraxia of Speech/CAS” or “Developmental Apraxia of Speech/DAS”

From my coauthor of The Late Talker book who is a neurodevelopmental pediatrician “Verbal apraxia is a neurologic speech disorder that results in a speech delay. My suggestion is that if you know that they will reject the diagnosis for some reason, work around it and use the terms they accept. In New York, we actually pay attention to diagnoses, and apraxia is one that automatically qualifies for services. If you don’t have that advantage. Don’t use the diagnosis then — Just get your foot in the door then teach your SLP about apraxia. Buy her a copy of The Late Talker!”

One of the sample letters from The Late Talker that can be used to help advocate for insurance:

Letter of Medical Necessity From The Doctor

This is an example of a letter for an insurance company, emphasizing that your child’s problem is neurologic and not developmental.

Re: LM
Date of Birth 3/10/09

Dear Dr. Smith,

LM a thirty -three-month-old boy, continues to carry the diagnosis of

742.9        Static Encephalopathy
388.40     Hypoxia at birth
784.69     Oral/verbal apraxia
783.3       Feeding disorder
781.3        Hypotonia, sensory integration dysfunction
388.40     Auditory processing disorder

He has made some improvement in speech and motor abilities, and has responded well to therapy.  He does, however, continue to require intensive treatments in order to overcome these disabilities.  They all have a neurologic basis and are not developmental.  Intensive treatment by qualified, experienced speech, physical and occupational therapists is required.  Oral/verbal apraxia of speech is a disorder where the brain signals that go to the muscles and structures of the speech mechanism are disrupted.  Without therapy, children do not outgrow verbal apraxia.  LM also has feeding problems associated with his speech disorder.  He requires speech treatment at least four times a week by experienced oral motor speech therapists who are trained in the PROMPT methodology.  He will also need occupational therapy two times a week by an occupational therapist knowledgeable about his sensory integration dysfunction and physical therapy once weekly to improve muscle coordination.  Without these therapists his prognosis is poor.

I am asking for three months of the therapies requested above followed by a reevaluation to assess programs.

Thank you for your assistance.

Yours truly,
A. Goode, M.D., F.A.A.P.

Also visit Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology from ASHA and the medical practitioners coding list from EICD

The following information is pulled from our groups for Cherab at one of our private or public support groups, and also shared on our document page.

Letter of Medical Necessity From The Parent

Hi, Lisa and others. Here’s a letter I wrote and used successfully to appeal a denial of insurance coverage on the basis that apraxia is developmental. This letter shows that apraxia is neurological and therefore medical, not developmental. Feel free to use, share, etc. Hope it helps someone out there!

SAMPLE LETTER:

[DATE]

VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED

[INSURANCE CO INFO]

To Whom It May Concern:

My son, __________, has been diagnosed with apraxia by his pediatrician, his pediatric neurologist, and his speech and language pathologist. (See enclosed information). To remediate this condition, Benjamin has been receiving speech and language therapy as well as occupational therapy (the apraxia affects his oral motor musculature as well as his fine and gross motor functions). His progress has been excellent, and all concerned believe continued therapy is crucial to overcoming this condition.

[HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT]

Since apraxia is a relatively uncommon condition, let me explain briefly what it is. Apraxia “‘is a neurological disorder that affects the planning and production of speech.” (Davis, Jakielski, & Marquardt, 1998)’.[It] is a loss in ability to voluntarily position the articulators (e.g., lips, jaw, tongue) on a consistent basis when speaking. This disorder interferes with the child’s sequencing of sounds into words. In other words, the child has the ability to produce the sounds, but when he/she tries to purposefully plan speech, the articulators do not always function together properly.” S. Whitebreak, C. Dvorak, and K. Jakielsi, “Treatment Effect on Speech Intelligibility in Developmental Apraxia of Speech,” Presentation at the American Speech-Language-Hearing Association, 1999.” This disability has a neurological basis of unknown origin. It may reflect neuro anatomical/physiological differences that are inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991).” It is similar to the condition stroke victims suffer from when they lose the ability to speak after a stroke. In fact, many children initially have speech ability but then lose it (as is the case with Benjamin, who had a larger vocabulary at 18 months of age than when diagnosed at 25 months of age).

As to the medical necessity of treatment of apraxia, the American Speech Hearing Association (ASHA) defines verbal apraxia as “a medical condition consistent with the definition of illness and disease.’ a disorder of body function.'” (Keystater, the official publication of the Pennsylvania Speech Hearing Language Ass’n, Sept.. 1992; Source: ASHA, Rockville, MD).

Apraxia is not a developmental disorder or childhood delay. If left untreated, my son will not develop meaningful speech or coordinated fine and gross motor abilities. Lack of meaningful speech and fine and gross motor abilities would result directly in a deterioration of my son’s health and safety, in that he will not be able to communicate medical needs and will be unable to function and daily life skills. With treatment, however, the prognosis is good. In fact, _____’s progress has been excellent.

Speech and occupational therapy are the recommended treatments for apraxia (see enclosed letters). They are the least expensive, least invasive, and most successful forms of treatment, are accepted by the medical community and are not implemented for the convenience of the child or therapist. See also Paula Square, “Introduction,” Clinics in Communication Disorders, 4(2) (“apraxia is a motor speech disorder in the ability to regulate and control oral movement sequences. Apraxia is a separate speech disorder that requires a motor treatment, apraxia is remediable if the clinician knows that this must be the focus of treatment”); Penelope Hall, Linda Jordan and Donald Robin, “Theory and Clinical Practices” (“Intensive services are needed for children with apraxia”); Edythe Strand, “Childhood Motor Speech Disorder Treatment,” (“The earlier and more intensive the intervention, the more successful the therapy. Children with apraxia really need the intensive individual therapy”).

In fact, the research indicates and experience dictates that apraxic children need intensive consistent therapy. The leading researchers in the field have indicated that this is the best therapeutic route to take. Such researchers include Edythe Strand, PhD., Mayo Clinic; Paula Square, Ph.D., University of Toronto; and Donald Robin, Ph.D., University of Iowa. The research indicates that the key to success is intensive therapy continually throughout the year.

In short, since apraxia is a medical condition and not a developmental delay or disorder, and since speech and occupational therapy are medically necessary, I submit that the enclosed expenses should be a covered benefit under the plan. Thank you for your consideration.

Sincerely,

Sandy, Illinois ([email protected])

Volunteer Co-Webmaster, www.ourchildrenleftbehind.com (IDEA re-authorization)

Tips for The Letter of Medical Necessity From A Parent Who Is A Doctor

I too am fighting a battle with CIGNA in order to get treatment authorized for my son’s apraxia (for the last year). Coming from a mom, a medical professional and someone having extensive experience working for an insurance type company, I have done the following: (this is not advice, as everyone’s situation is different, but just what I feel is most appropriate in my particular situation)

— I will always appeal a denial. Be aware of how many levels of Appeal your plan offers. Follow directions to the tee.

— I have documented the date, time and name of everyone I have spoken with at the insurance company in the last year.

— I request an urgent and expedited appeal. You have the right to request an urgent and expedited appeal on your child’s behalf. If you do this in writing the insurance company must make a decision on the appeal within three business days.

— I stick to the facts in my letter and quote research supporting the medical necessity of treatment.

— Physicians are busy – if you need a ‘good’ letter quoting research then write it yourself and ask the medical provider if they would be willing to sign on their letterhead.

— Read the exclusions of your benefit plan word for word. If you do not have a copy then ask your HR dept for the SPD (summary plan description).

— If your benefit plan excludes treatment that is not ‘restorative in nature’ then it is your employer’s plan that is excluding the treatment. I have personally called the VP of benefits at the company I work for, educating them on the diagnosis, referring them to this website and providing a copy of the recent Michigan ruling etc.. etc.. If a company

provides coverage for an adult with apraxia (after a stroke), athen a person should not be excluded from treatment just because of their age.

— If all your appeals have been upheld/denied then investigate next steps ie. contacting the insurance commissioner or the Dept of Labor (depending on your plan).

— If all else fails then I will be contacting my state representatives. I, like all of you, do not know how this will all turn out, having a plan makes me feel like I at least know the ‘next steps’. I am disappointed by the responses I have received on the first two appeals thus far, but I am not going to give up on this one without doing all that I can.

I didn’t mean to make this so long – I feel so strongly about this topic as I know so many of you do too- we are the voice for our kids. I wish you all the best in advocating for your children.

If your policy provides limited or no coverage for speech pathology services:

Find out if your employer offers another plan that provides coverage for speech and language services. If so, switch to that plan during the next open enrollment period.

Send a letter to your employer requesting better coverage in upcoming insurance plans. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Your company will have no idea of the need for speech therapy coverage unless you inform them that you were denied for coverage. Group insurance coverage for speech and language evaluations and therapy is a relatively inexpensive rider for most companies to add to their existing policies.

Inform your employer about any limitations in your plan, especially if your health insurance plan is self-insured by your employer. Your employer may be able to add speech services in future plans. Your state Department of Insurance may have limited jurisdiction over self-insured plans. With self- insured plans, the employer provides the money, decides what benefits to offer and what claims to pay. Theoretically, the insurance company just “follows orders.” The regulator over self-insured plans is the US Department of Labor, Pension and Welfare Benefits Administration at (202) 219-8776.

Yes, I had Aetna and Guardian. Aetna limited me and I fought back for the summer months b/c he was not in an ESY program, so therefore I had to use a medical based therapy for speech. I appealed 2 times and had a neurologist, speech pathologist, and OT evaluations requesting treatment was necessary due to regression. All reports were in medical terminology not educationally based.

If your employer has a medical benefits coordinator you may want to ask for their assistance in writing a letter requesting more therapy treatment sessions due to your child’s medical necessity.

Good luck!

Apraxia is a congenital disorder

Apraxia is a congenital (present at birth) disorder of the nervous system that affects a child’s ability to sequence and say sounds, syllables, and words. While this condition shares many of the symptoms of acquired apraxia, it doesn’t involve muscle weakness or paralysis. (source)

When your insurance company says “no”, it is not usually their final answer.

Question: Nancy W.C.

Long story short: My 3 y/o son has apraxia and is currently in an ECE program. This school doesn’t offer any kind of summer school so we’re looking into summer therapy…or even therapy during the school year. We have BCBS. We sent in all the paperwork to get a “predetermination”. It came back denied…basically, they’re only going to cover therapy unless he had an accident or some kind of illness, etc. <sigh> The paperwork we sent in included a letter of medical necessity from the EI speech therapist and dr…basically, we followed the suggestions in the Late Talker book.

Now what? I think I want to appeal the predetermination. Has anyone else had this issue? Does appealing even work? WHY doesn’t insurance cover this?? Very frustrated!!!

Answer:  Lisa Geng

The following is a compilation of answers to help!

I have not appealed a claims denial to BCBSNJ; however, I used to work for a company that had a small line of health insurance. Here are some suggestions.

1) Make sure you have the right diagnostic code since claims are paid based on diagnostic code. The Late Talker book has great suggestions.

2) If you have coverage under a group plan, you probably received a certificate of coverage or if an individual plan, an individual policy. In my opinion, the exclusions should be written in plain English so a reasonable person, i.e. the claimant, can understand them. Any ambiguities in the coverage language should be construed against the insurance company since you don’t get to negotiate the generic terms of the coverage. The insurance company has people whose job it is to write plans–if it wanted to exclude apraxia, one argument is that it could have written apraxia into the exclusionary language. If it not excluded, its probably covered.

3) If you have a separate insurance certificate, compare it to the master policy. Sometimes when companies keep two separate documents, the documents don’t get updated at the same time so look for conflicting coverage terms. Make sure you are reviewing the documents that are relevant for your point in time. Also, if you can, look at a new BCBSNJ policy to determine if it has rewritten its exclusions to exclude apraxia. If it did, it may mean that the company was likely concerned that apraxia wasn’t properly excluded before.

4) Not sure who reviews your plans on appeal. Consider the credentials of the reviewing panel–generally a specialist should trump a M.D. without further specialty–hard to know how to advise re this since am unfamiliar with the NJ process.

5) If possible, find out how other insurance companies treat apraxia and get a copy of their coverage language. If it is similar to yours and other companies consider apraxia covered, it is harder for BCBSNJ to state it isn’t. You may be able to find some similar cases where apraxia was covered by searching the internet (wasn’t there a Michigan BCBS case?). Don’t agree to anything against your favor in your appeal.

6) Some state regulatory agencies are more favorable to consumers than others. You might check with yours.

Insurance Help From An SLP

As an SLP, I have fought this battle over and over. Sometimes we are successful and sometimes we are not. You & your SLP should file an appeal; they are counting on you to NOT go through the trouble. Document the DX of Apraxia, supply information that apraxia has a neurological/medical component, do not code it as a developmental delay but use the code for apraxia (ask your SLP about this), document the fact that school services will not be available during this time period (if you only want summer TX, if you want it year round then leave this part out), supply any documentation on regression of skills for your child or children with apraxia in general when therapy is stopped. Be ready to ask for a 3rd level appeal and ask for an IRO (independent review) or 3rd party review. Also check with your state board of insurance (if your plan is not self-funded) as to the regulations. Oh, and I have also stated that their policy about “loss of speech” as being discriminatory against children who can “lose their potential for speech development in utero due to neurological events…” Good luck, be persistent!

Suzanne Couch Herman CCC SLP

Appeals Process Advice

Good luck! I have been all the way through the appeals process with BCBSNJ. I went and presented in front of their appeals committee in December.

They still rejected my claim. Perhaps you can learn from my mistakes! Here’s some advice:

1. Ask for the Master policy including any Gereral Exclusions. They rejected my claim based on the exclusion, “conditions, which the plan determines, are due to developmental disorders including, but not limited to, mental retardation, academic skill disorders, or motor skill disorders*** except as may be necessary to provide newly born dependents with coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and abnormalities.”

Since my doctors and therapists put “oral motor skills” in their reports, they rejected the claim. Lesson to be learned-find out what your exclusions say and try to avoid that wording. But, to be honest, I think they will find a reason to reject you anyway.(sorry to be a wet blanket).

2. They also told me that although the diagnosis is a neurological one, they were not convinced that he had a neurological disorder. Make sure you have a report from a neurologist.

3. They did compliment me on my presentation to them. If you would like more details on that feel free to email me privately.

They also told me that I could not get an external appeal, but I did file an appeal to the Department of Health. I have not heard from them yet.

Good luck…..it’s hard to reason with irrational folks!

Kate

Success With The Appeal Process by Nicole Kelley

Tips on how to win OT appeals against an insurance company when the plan is provided through a self-insured company. This could also apply for securing ST coverage as well:

1. Pay close attention to the criteria for coverage in your plan (i.e. illness/injury, etc.), and use it to support your argument. Specifically address and refute your insurance company’s reason for denial. If you do not address the denial reason(s) specifically, you will not win.

2. Even though Apraxia/Dyspraxia is a neurological disorder fitting the criteria for illness/injury, sometimes you will need to leverage any additional diagnosis(es) your child may have. In my instance, I leveraged my son’s diagnosis of Chronic Otitis Media (and how it relates to vestibular dysfunction) since there is no disputing that diagnosis as an illness. My son was also diagnosed with Hypotonia, but it is very, very mild. Nonetheless, it’s a diagnosis, so use whatever you have to your advantage to obtain coverage. Make sure to show the linkage of any subsequent diagnosis(es) to your child’s primary diagnosis. I proved that ear infections cause vestibular dysfunction, and many children with vestibular dysfunction also have Apraxia/Dyspraxia.

3. Appeal, appeal, appeal! Pay attention to the reason(s) for denial and do not be afraid to use strong (but professional) language stating why you and your child’s doctor disagree with the insurance company’s assessment. Do not be afraid to challenge the credentials of the doctor/nurse/etc. who made the determination on the insurance company’s behalf. After all, they work for the insurance company…

4. Get in touch with your company’s HR/Benefits department and request an internal appeal. My company has a Benefits Committee and I prepared an extensive packet of information supporting my argument for my son’s coverage. With self-insured companies, the company decides what claims to pay, and which ones to deny. Network within your company and request a meeting with the head of Benefits/HR (or however your hierarchy is established within your company). I had a face to face meeting with my Senior Benefits Manager to go over the documents I had prepared for the Benefits Committee meeting relating to my son’s appeal. This proved to be completely WORTH IT, because before my appeal went to the committee, the benefits manager emailed me and said they would overturn the insurance company’s decision and they will pay my son’s claims.

5. When meeting with your HR/Benefits department, be prepared to discuss ANY inconsistencies (if any exist) that the insurance company has displayed (i.e. if you receive different reasons for denial on levels 1 and 2 of your appeals, etc.).

6. Present the approximate dollar value of the claims to your HR/Benefits department. In my son’s instance, our plan allows for 50 OT visits per calendar year. Each visit is $80, and at 80% (which is what the plan would pay), that represents $3200 in cost to our employer and insurance company. As you go further in the appeals process and get to the point where an external/independent review is requested, these things cost your employer more money. My benefits manager stated that one independent review would cost them $600. If you can put an approximate dollar value on your claims, this helps your company assess whether or not it is worth their time and money to continue through the appeals process.

7. My employer offers coverage through 2 different insurance companies. Last year we were with Cigna, and they approved OT on the diagnosis of Hypotonia. This year we switched to Aultcare, and that is when the OT denials began. If you have a similar set up within your company where you have a choice of insurers, and your child was covered on one plan but not the other, make sure to tell your HR/Department about it! The plans are designed to be consistent, so if one approves, the other should approve based on the same criteria. Although Hypotonia was not used as the primary diagnosis when we received denials from Aultcare, the simple fact that my son has that diagnosis (although very mild) and it was covered under Cigna last year, the plans should be administered the same way if offered by the same self-insured company. This was actually the kicker that got my son coverage, even though my employer openly admitted that I more than proved the illness/injury argument with the Apraxia/Dyspraxia and Chronic Otitis Media diagnoses.

8. Obtain a letter from your child’s physician stating the medical necessity of your child’s therapies, and how it is illness/injury related (if that is your plan criteria for coverage). Even if you have to write it yourself and request that the doctor sign off on it, so be it. No one knows the details of your child’s case like you do, so who better to articulate the need for therapy? Utilize the social workers within your developmental pediatrician/neurologist’s office. They are there to help, and man….they are wonderful.

9. Network! Do your own due diligence and research, and don’t be afraid to reach out and ask for help. I’ve learned a ton by doing this, and people are more than willing to help. For this, I am grateful. You will be too when you and your child WIN your fight for coverage.

~ Nicole Kelley

Insurance questions…some better than others?

When your insurance company says “no”, it is not usually their final answer.

I do believe you have the right to three appeals. Let’s hope you get a yes on round two!

There are three levels of mediation

1. Written
2. Conference over the phone what you are up to:
3. The next if needed (or you could ask for) would be an in person conference with a higher up, and perhaps even someone who has a medical background. Good news is that the higher up you go –the more competent the person you are dealing with. While letters from the speech therapist are great, your child’s neuroMD (or pediatrician) is in the best position to determine medical necessity for an insurance denial, and can serve as a strong advocate in the appeals process. It is helpful to get a second opinion ‘and’ to include additional letters of medical necessity from specialists and therapists that support you.

Information I got years ago from a PhD who asked me never to use her name.

Ask for the master policy -they will tell you there is none. Ask to speak to that person’s superior and again ask for the master policy. They don’t like to give it out -but you need a copy for when you fight for coverage. I was also told that insurance companies deny because they know most won’t appeal.  By the second or third appeal you should either have a phone conversation or meeting with someone who has a medical background with more knowledge of your situation.

Insurance companies know that only 10% will appeal even the first denial -and many claims are denied that should be covered.

Out of that 10% only 10% will appeal the second denial. Out of that 10% (which is now down to a minute amount) only 10% will again appeal a denial.  By this point however-most do get approval.

Though families generally do not think of speech therapy when purchasing health insurance, talking is a necessary life function and, when disrupted, is life affecting. Many health insurance plans cover speech therapy. There are often limitations to the amount of coverage a member will receive, but in many cases the coverage is enough to provide for the needs of your child.

If you have concerns about your child’s language development, the first step is to take your child to see the pediatrician. Explain your concerns to the doctor. She will often provide you with a “referral” to have your child evaluated by a speech-language therapist. The “referral” is a part of the paperwork process often required by the insurance company. Your doctor might be familiar with your insurance company and its typical requirements. If she is not aware of your health insurance benefits, call the member services department at your insurance company to have them relay to you what steps you need to take to receive a speech-language evaluation. It is also a good idea to check your insurance benefits booklet for yourself so that you’re aware of the coverage. Not all insurance plans at the same insurance company provide for the same coverage.

Typically an insurance company will not deny the referral to the initial evaluation. After the evaluation, the speech therapist will tell you the diagnosis or give you a “working diagnosis”. She will also relay the diagnosis to the insurance company and make recommendations for treatment, if needed.

It is often at the point at which the speech therapist submits to insurance for pre-approval of the recommended speech therapy that families receive the first denial (by insurance) of the claim.

If you receive a denial, read through the following information to guide you in your appeal.

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.

-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  (Some codes have been updated since this page was created.  If you need a conversion for a code that has been updated you can find it here.)  You can also find speech therapy codes through ASHA here

Note:  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.

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

-Oral/verbal apraxia is a neurologic disorder so never use the word developmental (admin note: or childhood/CAS) or a code that is “developmental” in the report or on the bill.
-Useful ICD codes for Apraxia of Speech are  #R48.2, #F801 #R278 or R279. The latter code is also one used for Hypotonia, Sensorimotor Integration Disorder, and Coordination disorder, which may be associated with apraxia of speech.

“apraxia, acalculia, agnosia, agraphia” is R482. Generally, codes in this series are used for organic disorders. You should have neurological information supporting use of this code/diagnosis and should be able to answer the following questions:

• Is there a statement from a neurologist or pediatrician supporting a neurological component?
• How is this child’s verbal apraxia different from an articulation disorder?

(The Late Talker book)

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.”

Also, there is an entire chapter on advocacy for school and insurance in The Late Talker book -with sample letters my co-author Dr. Marilyn Agin wrote that your child’s MD can pull from to help you secure coverage/therapy. Do you have that book?

Health Insurance will not cover speech therapy – Help !!!

In addition to The Late Talker book here are some Quotes that May Help With Insurance Submissions For Apraxia from the Cherab Foundation website.

Below are some quotes and links that might help with the insurance submissions. If you receive a denial, hang in there — it’s common. Get the insurance company’s reasons for the denial and refute the reasons one by one. Insurance companies’ representatives (like so many others) don’t always know what apraxia is and leap to make presumptions that it’s something it’s not.

Insurance Letter For A Child With Apraxia Written By ASHA Posted in the Keystater (the publication of the Pennsylvania Speech Hearing Language Association), September, 1992.

“In July (1992) ASHA provided consumer assistance in obtaining payment for a child’s speech-language pathology treatment that the insurer had previously denied. ASHA sent a letter recommending payment by PA Blue Shield for speech-language pathology services for a young child diagnosed with verbal apraxia. PA Blue Shield denied payment stating the plan covered only illness-related speech-language therapy, and then only to restore speech to previously attained levels. Further it noted that ‘articulation disorders are not covered’.

“ASHA responded to the PA Blue Shield denial by describing verbal apraxia as a medical condition consistent with the definition of illness and disease, and that it is ‘a disorder of body function’. ASHA pointed out that the requirement that one must first possess an ability and then lose it does not allow for the medically related needs of infants and young children. Excluding ‘articulation disorders’ was noted to be perplexing because articulation disorders refer to many types of speech impairments that otherwise would be covered under the policy, such as cleft palate related speech impairments and dysarthria. ASHA observed the ‘policy language was akin to saying it provided treatment for broken bones, except for breaks of the arm or leg…’”Source: ASHA, Rockville, MD”

Megan Hodge, Associate Professor of Speech Pathology and Audiology, University of Alberta, Associate Professor of Speech Pathology and Audiology, University of Alberta, indicates that apraxia is neurological, whether it’s inherited, genetic, or due to injury:

“…This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, Auger, Graham, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991)…”

Part of an insurance appeal quote from a parent whose child has apraxia:

“It is illogical to say that (my son) only needs to communicate for educational purposes. (My son) is a three year old boy that can not tell anyone what his basic needs and wants are. Asking and telling is the only way for a toddler to communicate. What if he were to get separated from me? He can not tell anyone his name, where he lives, or who his parents are. His verbal skills must be developed, and not just for educational reasons, there are also major health concerns. (My son) can not tell me when something hurts…”

Information from Gina Mikel -a co founder of Apraxia Kids who created the original website for Apraxia and who built the http://www.cherab.org website

From: Gina Mikel co founder of Apraxia Kids

I remember a few people having this situation and successfully appealing it. They made the case based on the treatment being “medically necessary”, that because it was medically necessary that the child receive ongoing speech therapy, the limitation would not provide for the medical needs of the child. Others have stretched out the benefit by submitting for different types of therapy, oral motor speech therapy at one point, speech

therapy at another point, occupational therapy at another point. My sense about it would be that it would be a hard battle to wage. Have you checked into lower cost speech therapy through Scottish Rites, Easter Seals, or a local university’s speech-language clinic?

Gina

I have Aetna insurance. The policy allows for 60 consecutive days of therapy – that’s it. They tell me that’s not a yearly max – that’s a lifetime max. Has anyone fought this battle before and won? How would I go about it?

Thanks,

Debbie

Ilene’s post reminded me of something… Check your states’ regulations because those regulations can override the insurance policy. For example, this New Jersey legislation (below) indicates that if a physician states that speech therapy is medically necessary, and the speech therapy will be provided by a speech-language pathologist, then the person will not be denied the benefit. This should enable any child in New Jersey to get speech therapy as long as the pediatrician states that it’s medically necessary (regardless of 60 day limitations in the contract).

Gina

http://www.njleg.state.nj.us/9697/Bills/PL97/419_.HTM

17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services.

4.Notwithstanding any other provision of chapter 26 of Title 17B of the New Jersey Statutes, benefits shall not be denied to any eligible individual for eligible services, as determined by the terms of the policy or as otherwise required by law, when the services are determined by a physician to be medically necessary and are performed or rendered to that individual by a licensed audiologist or speech-language pathologist within the scope of practice. The practices of audiology and speech-language pathology shall be deemed to be within the provisions of chapter 26 of Title 17B of the New Jersey Statutes and duly licensed audiologists and speech-language pathologists shall have such privileges and benefits in the scope of their practice under that act as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.

L.1997,c.419,s.4.

Shannon,

Using Michigan as an example, I went to Google (http://www.google.com/) and typed in “michigan state government,” looking for the state’s home page. I found that and then looked for “legislature”, which led me to http://www.michiganlegislature.org/. I then clicked on “chapter index” and came to this page, http://www.michiganlegislature.org/mileg.asp?page=chapterIndex. The chapter index for each state lists the main topic areas for which there is legislation. This is applicable to educational legislation as well as insurance legislation, for those of you who might need to know what your state requires of the schools (usually provides more detail than what the federal legislation provides for).

Once you get to your state’s legislature’s chapter index, you can either search the entire database (if they offer that) using words like “speech therapy” “speech language pathologist” “occupational therapy” or “physical therapy” to see what the legislation provides for, or you can click on the specific chapter that pertains (Michigan’s include Chapter 550 GENERAL INSURANCE LAWS) and either search there or just start reading through stuff.

When I did this in Texas, I found information stating, for example, that therapists (speech, o.t., and physical) fell under the guidelines that the medical field falls under (ie it is appropriate for them to diagnosis within their area of expertise). I also found a statute that an SLP in Houston had referred to, one that states that in Texas, if any group of people will be provided an insurance benefit, than no other specific group of people will be excluded from receiving that same benefit. (In other words, if adults will receive speech therapy for a speech problem, then children shouldn’t be excluded from receiving speech therapy for that same problem simply because they’re children. In apraxia, the symptoms are often the same and both populations should be covered. One shouldn’t be excluded from coverage because the problem is deemed to be “developmental”.) (note from admin: and even if it starts in childhood should not be referred to or diagnosed as a childhood impairment either)

Another avenue that can lead you to pertinent statutes is to call your state’s speech language hearing association, your attorney general, and your state’s insurance department. Ask them if they’ve heard of statutes that might apply. Sometimes an email to your senator or representative can also help. His/her legal assistant might be willing to check into this for you.

Speech-language hearing associations for each state are listed here:

http://www.speech-express.com/speech-therapy/associations-state.html

Gina

Insurance information from neurodevelopmental pediatrician

Co-author with Lisa Geng of The Late Talker book

“Hi Susan,

Verbal apraxia is a neurologic speech disorder that results in a speech delay. My suggestion is that if you know that they will reject the diagnosis for some reason, work around it and use the terms they accept. In New York, we actually pay attention to diagnoses, and apraxia is one that automatically qualifies for services. I’m sorry that you won’t have that advantage. Don’t use the diagnosis then — Just get your foot in the door then teach your SLP about apraxia. Buy her a copy of The Late Talker!

Good luck!

Marilyn Agin, MD”

From: “Marilyn Agin M.D.”

-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 submission to the insurance company, here are some important tenets to follow:

-Oral/verbal apraxia is a neurologic disorder so never use the word developmental (admin note: or childhood/CAS) 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.

http://www.apraxia.org/

http://www.cherabfoundation.org/about/advisoryboard/marilyn-agin-md-developmental-pediatrician

Since post #263 was just a quick email written by neurodevelopmental pediatrician over 2 years ago now -if you really need help on how to deal with the insurance companies -the updated thorough version has grown up to become a bit larger -chapter 6 of The Late Talker book to be exact! -also in the appendix there are a couple of sample letters to the insurance companies to use as a guide -which is priceless (mom tested and insurance company approved) In the meantime because I’m guessing you don’t have The Late Talker book  -below is the email that helped many of us before there was a book that covered this.

Insurance

Key notes I learned  -probably try code 784.69 as a few people bring that one up as working – and read The Late Talker (we have an entire chapter on this in there and my co author is neurodevelopmental pediatrician who knows how to secure services for her qualified patients)

Aetna Insurance

We started Aetna on 1-1-07, I had carelink before and they refused to cover st after appeals. Fortunately my employer gives us a few options so we changed to Aetna. we had his pediatrician send a letter of med necessity and his neurologist send a letter stating

that apraxia is a neurological disorder and st was me nec. It took some arguing but they agreed to pay for unlimited visits. The code they are using is 784.69

Insurance advice

The book, The Late Talker, has a section on dealing with insurance. They say the key to getting treatment coverage for apraxia is to be clear this it is a neurological disorder, NOT developmental or childhood. Our coverage is just 20 sessions per calendar year of OT, PT, and ST each (60 total). And that is only AFTER an approval AFTER an insurance approved evaluation (which they might deny after we do it- $700) that convinces them this is needed. They will not accept the IEP or EI evaluations that we have. They joys of insurance…

After a recent doctor appointment, a diagnosis code of speech delay was entered in his chart. Apparently this is a code 315.31 that is listed as one to avoid as it is considered developmental/childhood and flags DENIAL for insurances. The book suggests using other codes like 784.69, 315.40 (most 315 codes are developmental except for this one), or 718.3. 718.3 also covers Motor Planning and Sensory processing, which affects him too. This often increases chances of coverage.

 Insurance appeal

Q Boo Mom

Diagnosis Destinations Apraxia Appealing Insurance Denials Apraxia is

“Developmental”. “Developmental delays” “Childhood delays” are not Covered.

Reason for Denial: “Apraxia is developmental. Developmental delays are not covered.”

One of the most important things to do when applying for insurance coverage of apraxia-related therapy is to ensure that the evaluator (that is, the speech-language pathologist) does not use the word “developmental” or “childhood” in his or her report, as in “Developmental Apraxia of Speech” or “Developmental Verbal Dyspraxia” or “Childhood Apraxia of Speech” or “Childhood Verbal Dyspraxia” Apraxia goes by many names. While some of these developmental or childhood terms may have been used without thinking in apraxia and speech therapy literature, for many families these phrases have been the sole cause of denials of insurance coverage. Insurance companies’ claims evaluators see the word “developmental” or “childhood” and think, “developmental delay or childhood 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 “Developmental Apraxia” or “Childhood Apraxia” is not the same as “developmental delay,” nor may he or she know that “Developmental Apraxia” or the more recently used by some outside of Cherab Foundation “Childhood Apraxia is used primarily to distinguish the condition from “Acquired Apraxia” (the loss of speech caused by a known incident of stroke or other brain trauma). The therapist should use a term such as “apraxia of speech,” “verbal apraxia” “oral motor planning disorder,” or “speech motor disorder.”

The insurance company might also be confusing apraxia of speech 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. Apraxia is not a “developmental disability,” though apraxia can co-occur, in some children, with a developmental disability. Regardless of whether or not a child is developmentally disabled, in addition to having apraxia of speech, the insurance company should not deny the claim on the basis of the developmental disability, if oral motor speech disorders 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 Apraxia of Speech 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” or “childhood” confusion, you will need to provide documentation to your insurance company or HMO demonstrating that apraxia of speech is not a developmental delay of speech. Apraxia of speech is disordered speech, speech that is not following a typical developmental path, whereas a child with developmentally delayed speech has typical speech patterns, albeit those of a younger child. Sometimes describing apraxia of speech as a neurological disorder or condition seems to help. Therefore here is a quote about the nature of apraxia from a well-known speech-language pathologist who specializes in apraxia of speech in children, Megan Hodge,

“…This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, Auger, Graham, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984;

Marquardt and Sussman, 1991)…”

 insurance appeal

Look at the procedure codes your professionals are using. We had Blue Cross and have a 20 session limit per year. My son has apraxia, aphasia (codes are 784.3,784.69 & 784.5)

Let your PT & OT know your codes for speech/language and not to use any developmental/educational codes. (just medical necessity).

Insurance battles are fought and won every day but you have to be persistent. What does their policy state as far speech therapy? Can you tell me the reason for denial?

Ask for the master policy -they will tell you there is none. They don’t like to give it out -but you need a copy for your appeal.

Physicians are busy – if you need a ‘good’ letter quoting research then write it yourself and ask the medical provider if they would be willing to sign on their letterhead.

Joanne

I wanted to share with you a really good resource for assistance in getting therapy and/or any other medical costs approved by your health insurance carrier. SNAP(special needs advocates for parents), a not for profit organization has a “medical insurance empowerment program” whereby they will review your insurance policy and medical reports for a processing charge of $10 (that is not a typo) and give you advice on how to deal with your insurance company. I dealt with Marla Kraus whom I found extremely knowledgeable, professional and personable. Their website

There of course is no guarantee that their advice will get the services you are looking for covered by your insurance company… but it is definitely a resource worth looking into.

Shana Tova to all,

Libby

You first need to find out if your plan covers speech therapy through your employer. Then have your developmental pediatrician write a letter of medical necessity using the code 781.49 which indicates an neuro-based motor planning disorder. If they use any other code with a 300 prefix, the insurer will deny based on childhood or developmental delay which they will not cover. Once, they receive the letter of medical necessity, it can take up to a month for review at which time, I would follow up on them every other day.

They are awful about communicating approval. It took us 2 months of back and forth frustrating follow-up calls, but eventually we won. They cover 60 visits annually.

I hope this helps. (Double check the code…look it up in the website…I’m pretty sure it is 781 the ending could be .69).

Myra

They denied us on the code for Apraxia 784.69 claiming its developmental which we all know it’s NOT, but they approved the therapy for the code for Language processing disorder 388.43.

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.

We have Blue Cross and have a 20 session limit per year. My son has apraxia, aphasia (codes are 784.3,784.69 & 784.5)

Let your PT & OT know your codes for speech/language and not to use any childhood/developmental/educational codes. (just medical necessity).

all the best,

Joanne

If your policy provides limited or no coverage for speech pathology services:

Find out if your employer offers another plan that provides coverage for speech and language services. If so, switch to that plan during the next open enrollment period.

Send a letter to your employer requesting better coverage in upcoming insurance plans. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Your company will have no idea of the need for speech therapy coverage unless you inform them that you were denied for coverage. Group insurance coverage for speech and language evaluations and therapy is a relatively inexpensive rider for most companies to add to their existing policies.

Inform your employer about any limitations in your plan, especially if your health insurance plan is self-insured by your employer. Your employer may be able to add speech services in future plans. Your state Department of Insurance may have limited jurisdiction over self-insured plans. With self-insured plans, the employer provides the money, decides what benefits to offer and what claims to pay. Theoretically, the insurance company just “follows orders.” The regulator over self-insured plans is the US Department of Labor, Pension and Welfare Benefits Administration at (202) 219-8776.

Regards,

Joanne

Insurance battles are fought and won every day but you have to be persistent. What does their policy state as far speech therapy? Can you tell me the reason for denial?

Article: Passing the Buck

By PAUL KRUGMAN

Published: April 22, 2005

The United States spends far more on health care than other advanced countries. Yet we don’t appear to receive more medical services. And we have lower life-expectancy and higher infant-mortality rates than countries that spend less than half as much per person. How do we do it?

An important part of the answer is that much of our health care spending is devoted to passing the buck: trying to get someone else to pay the bills.

According to the World Health Organization, in the United States administrative expenses eat up about 15 percent of the money paid in premiums to private health insurance companies, but only 4 percent of the budgets of public insurance programs, which consist mainly of Medicare and Medicaid. The numbers for both public and private insurance are similar in other countries – but because we rely much more heavily than anyone else on private insurance, our total administrative costs are much higher.

According to the health organization, the higher costs of private insurers are “mainly due to the extensive bureaucracy required to assess risk, rate premiums, design benefit packages and review, pay or refuse claims.” Public insurance plans have far less bureaucracy because they don’t try to screen out high-risk clients or charge them higher fees.

And the costs directly incurred by insurers are only half the story. Doctors “must hire office personnel just to deal with the insurance companies,” Dr. Atul Gawande, a practicing physician, wrote in The New Yorker. “A well-run office can get the insurer’s rejection rate down from 30 percent to, say, 15 percent. That’s how a doctor makes money. … It’s a war with insurance, every step of the way.”

Isn’t competition supposed to make the private sector more efficient than the public sector? Well, as the World Health Organization put it in a discussion of Western Europe, private insurers generally don’t compete by delivering care at lower cost. Instead, they “compete on the basis of risk selection” – that is, by turning away people who are likely to have high medical bills and by refusing or delaying any payment they can.

Yet the cost of providing medical care to those denied private insurance doesn’t go away. If individuals are poor, or if medical expenses impoverish them, they are covered by Medicaid. Otherwise, they pay out of pocket or rely on the charity of public hospitals.

So we’ve created a vast and hugely expensive insurance bureaucracy that accomplishes nothing. The resources spent by private insurers don’t reduce overall costs; they simply shift those costs to other people and institutions. It’s perverse but true that this system, which insures only 85 percent of the population, costs much more than we would pay for a system that covered everyone.

And the costs go beyond wasted money.

First, in the U.S. system, medical costs act as a tax on employment. For example, General Motors is losing money on every car it makes because of the burden of health care costs. As a result, it may be forced to lay off thousands of workers, or may even go out of business. Yet the insurance premiums saved by firing workers are no saving at all to society as a whole: somebody still ends up paying the bills.

Second, Americans without insurance eventually receive medical care – but the operative word is “eventually.” According to Kaiser Family Foundation data, the uninsured are about three times as likely as the insured to postpone seeking care, fail to get needed care, leave prescriptions unfilled or skip recommended treatment. And many end up disabled – or die – because of these delays.

Think about how crazy all of this is. At a rough guess, between two million and three million Americans are employed by insurers and health care providers not to deliver health care, but to pass the buck for that care to someone else. And the result of all their exertions is to make the nation poorer and sicker.

Why do we put up with such an expensive, counterproductive health care system? Vested interests play an important role. But we also suffer from ideological blinders: decades of indoctrination in the virtues of market competition and the evils of big government have left many Americans unable to comprehend the idea that sometimes competition is the problem, not the solution.

In the next column in this series, I’ll talk about how ideology leads to “reforms” that make things worse.[email protected]

Sharing on this page even though you can go directly to the original article here on iTaalk since so many looking for insurance help will also want to know how to get an iPad covered by insurance.

5 Steps to Getting an iPad Covered by Insurance: A mom’s story of success

Health insurance 🙁

Insurance companies, if they cover ST, will cover up to a number of day or dollar amount for DEVELOPMENTAL CPT code. But since apraxia is a Neurological DISORDER the neurologist can write a letter of medical necessity and then put in the correct CPT codes which are in the 700’s (your ST should know exact code) have them put the claim in that way with the letter and many times I have seen them cover and sometimes the members have had to fight and even after the fight have seem the insurance co. cover.

Insurance companies try to get around covering all types of therapies because they consider them “developmental” but we all need to go the route of “Disorder” and not use the word “therapy” either. These are all words for denial of service.

In the Late Talker book there is a complete section that explains how

to work the insurance system-please review-very good info!!!!

How To Make a Successful Insurance Appeal http://busyhomeschooler.com/?p=182

The answers above helped Nancy W.C.!

Wow, ladies…thanks…this really helps.

I have great news!! Using one of these letters as a template, I wrote to my insurance company, appleaing their decision to deny benefits. I sent the letter in late March. Called MANY times to follow up on it. FINALLY heard back the beginning part of JUNE…they ARE going to cover therapy up to $3,000. We can rack that up pretty quick but at least it’s SOMETHING!!!

Then, in addition to that, I found out about a non-profit organization called Small Steps in Speech that give away grants for children with speech issues. I applied and received money from them! They’ll pay for one hour a week for 15 weeks (basically to get us through the summer bc our school district doesn’t offer summer school). I am SO excited!!

The Pediatrician’s Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP)

Dealing with IEPs for a Speech Impaired Child

IEP Goals, Objectives, and Sample Letters to Teachers

5 Ways To Get Free or Affordable Speech Therapy

Guideline for Speech-Language Eligibility Criteria/Severity Intervention Matrix for Schools

More Info To Help

LISA GENG