My daughter's medical insurance is refusing anymore Physical Therapy for Cole, her 4 year old. She filed an appeal accompanied by a letter from his Physical Therapist, but they still denied it. Their reason for denial is, and I quote: "Your son has a progressive condition that will require self care and treatment for his entire life. At this time it falls on his family to provide him with the necessary support and encouragement to follow a home program and maintain his current gains." My daughter is now going to appeal this for the second time. I'm sure some of you have also run into this same problem. What is the best thing to tell them to get his much needed physical therapy? Terry

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Hi Terry,
I am an appeals nurse for an insurance company. The first thing your daughter needs to do is get a copy of her insurance benefits policy for physical therapy benefits. You need to know what their rules are for coverage. That way you can address the specific issues for coverage in the second appeal. Is there a yearly limit of visits, does the PT have to show updated goals and objectives and progress towards those goals. Do they only cover specific issues. Start there, you have to know what you are fighting in order to fight correctly.
What state do they live in, is his PT familiar with treating boys with DMD, it may be that a different tactic of letter is needed. Please let me know if I can help in any way!
Jennifer: Thank you for your reply. My daughter lives in NJ. Her insurance company said Cole is allowed 30 PT visits per year. Since he goes, once a week, that is 22 visits not covered. She is fighting for once a week visits. The person I spoke with on the phone said that in order for PT to continue, we have to show some sort of improvement. How do you measure improvement in DMD? I said that improvement in DMD is not measured in gains, but rather in the ability to keep the child from going into early contractures, deformity compromised lung and heart function. The consider this maintenance. How do I word it or the doctor or physical therapist word their letter to get this point across?

Jennifer Shumsky said:
Hi Terry,
I am an appeals nurse for an insurance company. The first thing your daughter needs to do is get a copy of her insurance benefits policy for physical therapy benefits. You need to know what their rules are for coverage. That way you can address the specific issues for coverage in the second appeal. Is there a yearly limit of visits, does the PT have to show updated goals and objectives and progress towards those goals. Do they only cover specific issues. Start there, you have to know what you are fighting in order to fight correctly.
What state do they live in, is his PT familiar with treating boys with DMD, it may be that a different tactic of letter is needed. Please let me know if I can help in any way!
What the PT needs to have is measureable goals and objectives. So at 4 that will be pretty easy to do. My son at 7 is still improving at PT. Goals can be as basic as : Will be able to ride modified tricycle 25 feet without breaks in 25% of attempts over 6 weeks, then when that goal is achieved (that is measurable in progress reports) then the next goal is in 50 % of trials over 6 weeks, then 100% of trials over 6 weeks, then you move on to 50 feet etc..., other goals we have done is safety on playground equiptment, balance beam work etc. At the younger ages there is still improvements that can be made and measured. Our therapy facility see's about 7 boys with DMD, so they are quite familiar with the disease and insurance company's needs.
I am leaving work soon. When I get home I will find Xavier's progress reports from PT and give you his examples. I can even fax you some if you would like. My personal email is jlshumsky@comcast.net
Talk to you soon!
Forgot it's dance class night for Erica, we are off to 3 and 4 year old tap and ballet! (so much fun and joy!) I won't forget...but it will be later tonight..feel free to email me or I'll peek in here!
Hi Terry. Your initial message was from September so hopefully your daughter has been successful at getting coverage for the additional visits since then. If not let me kow if I can be helpful in any way. I'm a pediatric PT in NJ and its all in the wording to get the approval. Like Jennifer said the goals are key and proving that he needs coverage should be very doable. If the insurance company things the therapy is to "maintain", forget it, they're not looking at the long-term importance of PT in preventing more serious problems in the future. I've worked in several states and NJ has seemed the most difficult to me with insurance companies.

Terry Porcaro said:
Jennifer: Thank you for your reply. My daughter lives in NJ. Her insurance company said Cole is allowed 30 PT visits per year. Since he goes, once a week, that is 22 visits not covered. She is fighting for once a week visits. The person I spoke with on the phone said that in order for PT to continue, we have to show some sort of improvement. How do you measure improvement in DMD? I said that improvement in DMD is not measured in gains, but rather in the ability to keep the child from going into early contractures, deformity compromised lung and heart function. The consider this maintenance. How do I word it or the doctor or physical therapist word their letter to get this point across?

Jennifer Shumsky said:
Hi Terry,
I am an appeals nurse for an insurance company. The first thing your daughter needs to do is get a copy of her insurance benefits policy for physical therapy benefits. You need to know what their rules are for coverage. That way you can address the specific issues for coverage in the second appeal. Is there a yearly limit of visits, does the PT have to show updated goals and objectives and progress towards those goals. Do they only cover specific issues. Start there, you have to know what you are fighting in order to fight correctly.
What state do they live in, is his PT familiar with treating boys with DMD, it may be that a different tactic of letter is needed. Please let me know if I can help in any way!
Hi Joni: Actually, this is still not resolved. Jennifer Shumsky and Patti Frank were both very helpful to us, but if you could give me some ideas on the "wording", I would be very grateful. They are denying my grandson any further PT therapy at all. The reason, and I quote: "He has a progressive disease condition that will require self care and treatment for his entire life. At this time it falls on his family to provide him with the necessary support and encouragement to follow a home program and maintain his current gains." Also, "Maintenance PT services are not considered medically necessary. Maintenance is the point at which no further improvement in restoration of function, reduction in disability, or relief of pain is demonstrated or expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration." What wording could we use to argue against this denial? Terry

Joni said:
Hi Terry. Your initial message was from September so hopefully your daughter has been successful at getting coverage for the additional visits since then. If not let me kow if I can be helpful in any way. I'm a pediatric PT in NJ and its all in the wording to get the approval. Like Jennifer said the goals are key and proving that he needs coverage should be very doable. If the insurance company things the therapy is to "maintain", forget it, they're not looking at the long-term importance of PT in preventing more serious problems in the future. I've worked in several states and NJ has seemed the most difficult to me with insurance companies.

Terry Porcaro said:
Jennifer: Thank you for your reply. My daughter lives in NJ. Her insurance company said Cole is allowed 30 PT visits per year. Since he goes, once a week, that is 22 visits not covered. She is fighting for once a week visits. The person I spoke with on the phone said that in order for PT to continue, we have to show some sort of improvement. How do you measure improvement in DMD? I said that improvement in DMD is not measured in gains, but rather in the ability to keep the child from going into early contractures, deformity compromised lung and heart function. The consider this maintenance. How do I word it or the doctor or physical therapist word their letter to get this point across?

Jennifer Shumsky said:
Hi Terry,
I am an appeals nurse for an insurance company. The first thing your daughter needs to do is get a copy of her insurance benefits policy for physical therapy benefits. You need to know what their rules are for coverage. That way you can address the specific issues for coverage in the second appeal. Is there a yearly limit of visits, does the PT have to show updated goals and objectives and progress towards those goals. Do they only cover specific issues. Start there, you have to know what you are fighting in order to fight correctly.
What state do they live in, is his PT familiar with treating boys with DMD, it may be that a different tactic of letter is needed. Please let me know if I can help in any way!
Hi Joni: I haven't heard back from you. Did you see my reply to you on 12/1/08? I know that it's key to get the wording right to appeal Cole's PT denial with the insurance company. If you can suggest any "wording" I can use, I would be most appreciative. Terry

Joni said:
Hi Terry. Your initial message was from September so hopefully your daughter has been successful at getting coverage for the additional visits since then. If not let me kow if I can be helpful in any way. I'm a pediatric PT in NJ and its all in the wording to get the approval. Like Jennifer said the goals are key and proving that he needs coverage should be very doable. If the insurance company things the therapy is to "maintain", forget it, they're not looking at the long-term importance of PT in preventing more serious problems in the future. I've worked in several states and NJ has seemed the most difficult to me with insurance companies.

Terry Porcaro said:
Jennifer: Thank you for your reply. My daughter lives in NJ. Her insurance company said Cole is allowed 30 PT visits per year. Since he goes, once a week, that is 22 visits not covered. She is fighting for once a week visits. The person I spoke with on the phone said that in order for PT to continue, we have to show some sort of improvement. How do you measure improvement in DMD? I said that improvement in DMD is not measured in gains, but rather in the ability to keep the child from going into early contractures, deformity compromised lung and heart function. The consider this maintenance. How do I word it or the doctor or physical therapist word their letter to get this point across?

Jennifer Shumsky said:
Hi Terry,
I am an appeals nurse for an insurance company. The first thing your daughter needs to do is get a copy of her insurance benefits policy for physical therapy benefits. You need to know what their rules are for coverage. That way you can address the specific issues for coverage in the second appeal. Is there a yearly limit of visits, does the PT have to show updated goals and objectives and progress towards those goals. Do they only cover specific issues. Start there, you have to know what you are fighting in order to fight correctly.
What state do they live in, is his PT familiar with treating boys with DMD, it may be that a different tactic of letter is needed. Please let me know if I can help in any way!

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