Wondering if this is just my insurance or if others are having a problem?
Michael does aquatic therapy every Wednesday and physical therapy 2 times a month. His original diagnosis was developmental delay but now that his 90 visits are completed They will not cover either because he has a non curable medical diagnosis. I have spoke with 3 different people at this insurance company and they all say the same thing. I am absolutely dumbfounded by this. Anybody with any of the same problems?:???

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We haven't had any problems with covering my son's PT/OT/AT as long as we're within the 60 visits per year. Once we hit 60, they won't cover a dime of the expense... :(

Fortunately, our state (Michigan) has a special program for children with special needs, which picks up the costs of PT/OT/AT after our insurance covers the first 60 visits.

Not sure where you are, but you might check into your state's offerings...

Keith
I would refer to your insurance policy on this, is it because of his condition, or does your insurance only cover 90 visits combined a year? There is a big difference on that.
I am an appeals nurse for an insurance company so I can help on this but we need to know plan language first and foremost. If they are denying based on diagnosis then you can appeal for treatment as long as he is showing improvement towards measurable goals and functional deficits. At his age I am sure his short term and long term goals are ever changing and he should still be showing improvement towards his goals. My Son is almost 8 and is still showing improvements and gains towards his goals on his treatment plans.
Get a copy of the exact plan language and your EOB denial if you'd like some help and let me know what it says and we can work from there on what kind of appeal chances you have an what you need to do to appeal.
Nicole,

Do you have the states back up insurance? The backup should pay for the PT but not sure about the aquatic.
I pay for the aquatic and hippo for my son in PA. I use back up for OT/PT.

Darcy
As Darcy posted, suggest you get signed up for PA Medicaid, they are a great help in picking up when your primary coverage exhausts and also for copays. Every little bit helps. You can apply on line at www.compass.state.pa.us. I was very surprised when I applied, how easy the process was.
Jennifer,
Thanks for your insight. What do you recommend to do when your son stops walking, ie is almost 18 and not showing improvement anymore?

Thanks, Cheri

Jennifer Shumsky said:
I would refer to your insurance policy on this, is it because of his condition, or does your insurance only cover 90 visits combined a year? There is a big difference on that.
I am an appeals nurse for an insurance company so I can help on this but we need to know plan language first and foremost. If they are denying based on diagnosis then you can appeal for treatment as long as he is showing improvement towards measurable goals and functional deficits. At his age I am sure his short term and long term goals are ever changing and he should still be showing improvement towards his goals. My Son is almost 8 and is still showing improvements and gains towards his goals on his treatment plans.
Get a copy of the exact plan language and your EOB denial if you'd like some help and let me know what it says and we can work from there on what kind of appeal chances you have an what you need to do to appeal.
Cheri,
It is so much harder to obtain coverage once they are not walking, or there is no acute need for therapy. Medicare even requires acute need, they do not pay for maintenance care. For many insurance groups you can get your 90 visits and that is it and your appeal will fall on deaf ears. Once they are not showing improvements you still would want to be able to show the medical necessity for whatever therapy you are providing. As a nurse you know there is still a need to prevent contractures, foot drop, blood clots,etc...even pool therapy can provide some improvements for boys that are immobile if they are given the chance. The key is to make sure the medical necessity is shown, have a strong treatment plan in place and then show that the treatment plan is being executed.
Thanks for all the tips. I am spending today trying to figure all this out.
Jennifer,
Thanks for the info. We work very hard at the stretches but it is very hard to keep the contractures at bay.

cheri

Jennifer Shumsky said:
Cheri,
It is so much harder to obtain coverage once they are not walking, or there is no acute need for therapy. Medicare even requires acute need, they do not pay for maintenance care. For many insurance groups you can get your 90 visits and that is it and your appeal will fall on deaf ears. Once they are not showing improvements you still would want to be able to show the medical necessity for whatever therapy you are providing. As a nurse you know there is still a need to prevent contractures, foot drop, blood clots,etc...even pool therapy can provide some improvements for boys that are immobile if they are given the chance. The key is to make sure the medical necessity is shown, have a strong treatment plan in place and then show that the treatment plan is being executed.
Hi Nicole,
We've had luck by obtaining medical assistance as the boys' secondary insurance. We still use our primary insurance that we always had, but have been able to have unlimited PT visits through the secondary policy. The boys are eligible due to their diagnosis. It also picks up the costs that our primary insurance doesn't cover. It can be a little tricky because you need providers that accept both of your insurances, but we've had luck using Theraplay for PT. The boys have Keystone Mercy as their secondary insurance. Hope that's helpful! Lauren Fritz

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