Insurance company denied OT

iVillage Member
Registered: 04-04-2003
Insurance company denied OT
8
Wed, 08-22-2007 - 5:34pm

Hi folks,
DD, Abby (4, diagnosed this Spring with PDD-NOS, independent nueropsch eval) was approved for 25 OT visits within a 60 day period. DH and I work so we were lucky to get her to OT twice a week. Well, we only used 11, but the 60 day period is over so the OT requested more visits ongoing. They denied the request so Abby's OT is over effective Monday. Argh! I called the insurance company, explained the situation and they were less than helpful and said they would send me the forms to appeal the decison. She has done so well, I'd hate to have it end. Abby's CORE evaluation from the school system isn't until October and I'm pretty sure they will agree that she needs the OT services, but I don't want to go without the OT until then.

Has anyone appealed with an insurance company before? Any advice? I'd love to get some sample letters, if possible.

Thanks in advance!

Patty from Boston

Patty and Abby 1/28/03

iVillage Member
Registered: 04-28-2007
Wed, 08-22-2007 - 8:16pm

Is Abby getting servics from the school system at all? Insurance co's are absolute sheisters so don't get me started there...fume!!! However if Abby needs OT and you can get the school to do an eval you may qualify for OT that way. I know this sucks. the 25 within 60 day period is ridiculous, especyially is they think 25 whammied visits in 2 months will "fix" it....sigh

GL

Dee

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iVillage Member
Registered: 04-04-2003
Wed, 08-22-2007 - 9:45pm

No services through the school system yet. She is starting parochial school in September. We enrolled her before the diagnoses (even though in my heart I knew there was something going on with her), so we initiated the process for a public school evaluation in June right before their school year ended. They are doing the evaluation in October. It's likely that we may find the Catholic school she is going to in September won't end up being the right place for her, but we may be able to keep her there with some services through the public school. I really pushed for the OT in the summer, but I think they (sheisters) know she is probably going to school in September.

The nim-rod on the phone actually said "in most cases 25 visits are more than enough to resolve any issues". "Uh, with all due respect (which, when I start with that, it's code for "Hey A-hole") this is a pervasive development disorder which will not go away magically in 25 visits". I will appeal, with vigor and venom (with "all due respect" of course)--it may not change things, but I can't let them get away with this.

Thanks!

Patty and Abby 1/28/03

iVillage Member
Registered: 03-20-2003
Wed, 08-22-2007 - 11:32pm

Oh Patty that is horrible!

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iVillage Member
Registered: 01-25-2007
Thu, 08-23-2007 - 5:04am
One thing to keep in mind is that the O.T. offered by schools might be nothing like what you've been getting in private O.T. Meaning that they will focus only on those weaknesses that they believe will affect academics. My son was diagnosed first with PDD-NOS and then it was refined to Asperger's. The private O.T. did some work each session with his handwriting, but most of the sessions were devoted to core body strength and balance. This must come first before the fine motor skills can be improved. The school O.T. evaluated him and decided that he didn't need O.T. at all. Never mind that his core strength is so weak he can't maintain his posture when sitting. Never mind that his fine motor skills are so weak that he has meltdowns whenever he is given long writing assignments. Never mind that he forms all of his letters from the bottom up, adding to the fatigue. I would continue to fight for the Private O.T. reguardless of what she ends up getting in school. Can the private O.T. provide you with an evaluation of her weaknesses to help in your appeal?
iVillage Member
Registered: 06-25-2003
Thu, 08-23-2007 - 8:09am

Patty,


Frankly, I'm impressed that you got OT approved in the first place. They are notorious for refusing services for anything to do with an ASD.

-Paula

visit my blog at www.onesickmother.com
iVillage Member
Registered: 11-28-2006
Thu, 08-23-2007 - 11:19am

Insurance co's are notorisly known for denying services when they really should be covered.

They know that their supposed to, but figure hey lets see if we can deny this and the parent will just go along and not fight us. Lots of times if you put in a fight they give in.

Good luck!

Lainie

iVillage Member
Registered: 07-24-2003
Thu, 08-23-2007 - 11:27am

We had a very similar fight with our insurance company. One of the first things to do is to contact your benefits person at work. Often they can do things that you can't by contacting the customer service people. For one they deal with salespeople, who want to continue to be a company's provider. Second they have access to people who actually understand the details of your company's specific plan and any differences in coverage from a basic plan. I call our benefits person so often I now have home and cell phone numbers for them. Also have a talk with the service provider. Sometimes they can be more successful than you at getting things paid for. After all, they are the ones that untimately want to be paid, and they have a lot more experience getting these things pushed through. Our OT/PT provider handles everything for us now. They are great! They even managed to get the co-pay waived somehow. Good luck.

Mary

iVillage Member
Registered: 04-04-2003
Thu, 08-23-2007 - 6:59pm

Thanks so much for your responses. Very good advice and I really appreciate it. This will be the first time I have had to really fight for something for Abby--unfortunately I'm sure it won't be the last time.

Patty

Patty and Abby 1/28/03