December was the last time Teddy had outpatient physical therapy approved by Medicaid, which is his secondary insurance coverage. January is when the denial for PT arrived, after a few weeks of processing. The first week in March is when the hearing happened, via telephone of course to prevent me from dramatically marching Teddy into the hearing to show everyone why it's obvious he needs both outpatient PT and PT in the school setting.
I do realize, of course, that my dramatic entrance entrance would have been followed by me spending the entire hearing wrestling Teddy, which wouldn't have been overly effective. Not that it matters because last week in mid-April is when the hearing decision upholding the denial arrived in our mailbox.
It took 4 months to go through the process to get told there's no way Medicaid will cover PT for Teddy through outpatient clinic while he's receiving it in the school setting ... but we could file a request for services now to see if Medicaid will cover PT during the summer since Teddy doesn't qualify for summer services through the school. (That's a whole other bucket o' slimy worms that I'm not going to dig into right now.)
Let me do the math. Mid-April plus 4 months equals mid-August. That's right when Teddy's about to go back to school where he'll be getting PT services again. And that means, they wouldn't cover services because it would be duplicate services.
What are the odds that Medicaid grants the request right away for summer? How much will my PT hate me if I make her go through all the paperwork and process all over again? Why do we have to wait so long to get an answer on therapy ... and why do we have to request services every 3 months or so? How on earth does OT get approved right away for Teddy (not that I'm complaining!)?
So for now, we say to heck with Medicaid. We're trying to work with our clinic to run his therapy services for PT through only our primary insurance, which theoretically will work to get Teddy the therapy that benefits him.
And we're hoping it works for speech, too, because we just received that denial. I'm not sure I have the wherewithal to go through that appeal process, only to have it denied with the exact same language as the PT hearing decision I have in my hands.
Showing posts with label appeal. Show all posts
Showing posts with label appeal. Show all posts
Monday, April 24, 2017
Thursday, March 2, 2017
PT Appeal
I've talked in the past about not accepting an insurance denial, but today was a new experience in the world of insurance appeals for me. Teddy's physical therapist submitted a request for 5 visits, one a month, back in November 2016. In January 2017, his state coverage (which is his secondary insurance) finally decided to deny the request.
I filed a letter to appeal that decision within a day of receiving the denial. A couple weeks later, I learned the next step in the process would be a hearing with an Administrative Law Judge (ALJ). That threw me for a loop because I had expected some sort of record review along the lines of previous appeals.
Fortunately, my requests for assistance through the Congenital Disorders of Glycosylation (CDG) Facebook group and PIGN Facebook group were met with an immediate positive response. A few people provided reference papers and other documentation to support the medical necessity of physical therapy for similar diagnoses. A mom whose two sons have a similar diagnosis to Teddy promptly connected me with her friend, who has extensive background within insurance companies. This friend of a friend, neither of whom I've ever met, spent a half hour on the phone with me walking through what I needed to do to prepare. Another mom whose daughter has the same diagnosis as Teddy wrote a thorough patient/parent testimonial regarding the medical necessity and benefits of physical therapy for her child.
Of course, this appeal process also required me spending nearly 1.5 hours on the phone on hold with various doctor's offices and Medicaid itself to try to request different documentation ... which I never really received. In fact, I spent nearly an hour on the phone requesting something from Medicaid only to receive a useless 1-page sheet that wasn't anything along the lines of what I requested.
Then last week I received Medicaid's position statement, detailing why PT was denied. Apparently the denial wasn't based on the fact that PT wasn't medically necessary as much as the fact that it's a duplicative service because he receives physical therapy in the school setting. In my mind, that weakened the really strong argument I had prepared about strictly the medical necessity of the service. I spent the remainder of last week on my runs (which I should be doing a run right now instead of rambling here) plotting my arguments, compiling my potential exhibits and worrying about the outcome.
And then I had two sick children this week, with Teddy home from school every day. That pulled my attention from the appeal somewhat but also eliminated other time I had planned to review and prepare.
Today was the hearing, which gave me a sense of deja vu. In my life before kids, I attended many unemployment hearings in my role as HR Director. The format of this hearing was identical to those hearings. Who knew all those hearings would serve as practice for this?
We'll know within the next month whether the denial is reversed. So, if it is reversed, does that mean he gets 5 PT visits in 1.5 months since it's taking 3.5 months to go through this process?
I filed a letter to appeal that decision within a day of receiving the denial. A couple weeks later, I learned the next step in the process would be a hearing with an Administrative Law Judge (ALJ). That threw me for a loop because I had expected some sort of record review along the lines of previous appeals.
Fortunately, my requests for assistance through the Congenital Disorders of Glycosylation (CDG) Facebook group and PIGN Facebook group were met with an immediate positive response. A few people provided reference papers and other documentation to support the medical necessity of physical therapy for similar diagnoses. A mom whose two sons have a similar diagnosis to Teddy promptly connected me with her friend, who has extensive background within insurance companies. This friend of a friend, neither of whom I've ever met, spent a half hour on the phone with me walking through what I needed to do to prepare. Another mom whose daughter has the same diagnosis as Teddy wrote a thorough patient/parent testimonial regarding the medical necessity and benefits of physical therapy for her child.
Of course, this appeal process also required me spending nearly 1.5 hours on the phone on hold with various doctor's offices and Medicaid itself to try to request different documentation ... which I never really received. In fact, I spent nearly an hour on the phone requesting something from Medicaid only to receive a useless 1-page sheet that wasn't anything along the lines of what I requested.
Then last week I received Medicaid's position statement, detailing why PT was denied. Apparently the denial wasn't based on the fact that PT wasn't medically necessary as much as the fact that it's a duplicative service because he receives physical therapy in the school setting. In my mind, that weakened the really strong argument I had prepared about strictly the medical necessity of the service. I spent the remainder of last week on my runs (which I should be doing a run right now instead of rambling here) plotting my arguments, compiling my potential exhibits and worrying about the outcome.
And then I had two sick children this week, with Teddy home from school every day. That pulled my attention from the appeal somewhat but also eliminated other time I had planned to review and prepare.
Today was the hearing, which gave me a sense of deja vu. In my life before kids, I attended many unemployment hearings in my role as HR Director. The format of this hearing was identical to those hearings. Who knew all those hearings would serve as practice for this?
We'll know within the next month whether the denial is reversed. So, if it is reversed, does that mean he gets 5 PT visits in 1.5 months since it's taking 3.5 months to go through this process?
Wednesday, October 15, 2014
Never Accept an Insurance Denial
I still recall how frustrated I was when our insurance company denied speech therapy for Teddy. At that time, he was 15-months old and completely non-verbal. He lacked the ability to attend to toys and honestly interact much with people including making eye contact and tracking motions. His speech scores were the lowest of all his test scores, with many of his skills in the 0-3 month range. That's tough for a parent to hear, although we obviously knew he wasn't going to score well.
Even tougher was hearing that the insurance company didn't feel it was necessary for him. At first, I was downright mad. Many an inappropriate word left my mouth, and it was very difficult not to write an appeal based on emotion. Instead, I did what research I could and wrote an appeal based on as many factual aspects as possible, which was a bit difficult without a true diagnosis for Teddy. This was the appeal:
Dear Sir or Madam:
My son, Theodore Blondheim, is a 15-month-old boy who has been diagnosed with hypotonia by his pediatric neurologist. To remediate this condition, Theodore has been receiving occupational therapy and physical therapy and has met several of his therapeutic goals in these areas within the past two months. All concerned believe continued therapy is crucial to overcome this condition.
Humana denied a request to begin speech therapy for Theodore beginning September 11, 2014. The denial was issued because therapy was deemed a non-medically necessary service to address learning disabilities.
Theodore’s hypotonia affects the muscles throughout his body and is not restricted to his trunk. His hypotonia affects his oral motor musculature. A child with hypotonia, “lacks head and chest control and exhibits low tone in the face and mouth. Sucking, chewing and swallowing are difficult for these infants and toddlers. Drooling food and saliva from the mouth is common and may persist in the school age child,” according to “Early recognition and intervention is the key to recovery for Benign Congenital Hypotonia” by Shannon Munro Cohen, RNC, BSN and Teresa Whitt, Ph.D.
Theodore has demonstrated constant drooling, unassociated with periods of teething. With the assistance of his occupational therapy, Theodore has learned the motions of bringing a sippy cup to his mouth to drink. However, Theodore is unable to properly swallow liquids from sippy cups without soiling his shirt within a few sips as he lacks the muscle control to appropriately drink from a sippy cup. When Theodore wears a pocket bib, the entire pocket of the bib is filled with the liquid within 5 minutes of attempting to drink.
Hypotonia is not a developmental disorder or childhood delay. If left untreated, my son will not properly develop meaningful speech or coordinated motor abilities related consumption of food and beverages. Lack of meaningful speech and these 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 in daily life skills involving eating and drinking that are directly related to his health and wellbeing.
Speech therapy is among the least expensive and least invasive form of treatment accepted by the medical community and is not implemented for the convenience of the child or therapist.
Since hypotonia is a medical condition and not a developmental delay or disorder, and since speech and therapy is medically necessary, we are asking for three months of speech therapy followed by a reevalution.
Thank you for your assistance.
Within a month or so, the initial decision was reversed, and we were into speech therapy with an awesome pediatric speech therapist. Teddy has benefited so much from this therapy, and we were so happy to get it approved for him. (Unfortunately, at the time I'm writing this post, we're waiting yet again for re authorization of speech therapy.)
Even tougher was hearing that the insurance company didn't feel it was necessary for him. At first, I was downright mad. Many an inappropriate word left my mouth, and it was very difficult not to write an appeal based on emotion. Instead, I did what research I could and wrote an appeal based on as many factual aspects as possible, which was a bit difficult without a true diagnosis for Teddy. This was the appeal:
Dear Sir or Madam:
My son, Theodore Blondheim, is a 15-month-old boy who has been diagnosed with hypotonia by his pediatric neurologist. To remediate this condition, Theodore has been receiving occupational therapy and physical therapy and has met several of his therapeutic goals in these areas within the past two months. All concerned believe continued therapy is crucial to overcome this condition.
Humana denied a request to begin speech therapy for Theodore beginning September 11, 2014. The denial was issued because therapy was deemed a non-medically necessary service to address learning disabilities.
Theodore’s hypotonia affects the muscles throughout his body and is not restricted to his trunk. His hypotonia affects his oral motor musculature. A child with hypotonia, “lacks head and chest control and exhibits low tone in the face and mouth. Sucking, chewing and swallowing are difficult for these infants and toddlers. Drooling food and saliva from the mouth is common and may persist in the school age child,” according to “Early recognition and intervention is the key to recovery for Benign Congenital Hypotonia” by Shannon Munro Cohen, RNC, BSN and Teresa Whitt, Ph.D.
Theodore has demonstrated constant drooling, unassociated with periods of teething. With the assistance of his occupational therapy, Theodore has learned the motions of bringing a sippy cup to his mouth to drink. However, Theodore is unable to properly swallow liquids from sippy cups without soiling his shirt within a few sips as he lacks the muscle control to appropriately drink from a sippy cup. When Theodore wears a pocket bib, the entire pocket of the bib is filled with the liquid within 5 minutes of attempting to drink.
Hypotonia is not a developmental disorder or childhood delay. If left untreated, my son will not properly develop meaningful speech or coordinated motor abilities related consumption of food and beverages. Lack of meaningful speech and these 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 in daily life skills involving eating and drinking that are directly related to his health and wellbeing.
Speech therapy is among the least expensive and least invasive form of treatment accepted by the medical community and is not implemented for the convenience of the child or therapist.
Since hypotonia is a medical condition and not a developmental delay or disorder, and since speech and therapy is medically necessary, we are asking for three months of speech therapy followed by a reevalution.
Thank you for your assistance.
Within a month or so, the initial decision was reversed, and we were into speech therapy with an awesome pediatric speech therapist. Teddy has benefited so much from this therapy, and we were so happy to get it approved for him. (Unfortunately, at the time I'm writing this post, we're waiting yet again for re authorization of speech therapy.)
That wasn't the only appeal we had to write. He was denied for genetic testing to test a specific gene related to seizures. As much as the speech therapy denial upset me, I was livid with this one because he had two seizures within two days of receiving the denial. Once again, I tried to appeal with reason instead of emotion, and this was the appeal:
Dear Sir or Madam:
My son, Theodore Blondheim, is a 16-month-old boy who is currently diagnosed with febrile seizures by his pediatric neurologist. However, Theodore’s seizures do not follow the typical pattern of febrile seizures, which is why Theodore was referred for genetic testing and consultation. Theodore has had five separate seizure episodes, two of which involved multiple seizures, with the most recent episode occurring November 16, 2014. According to the National Institute of Neurological Disorders and Stroke, “The majority of children with febrile seizures have rectal temperatures greater than 102 degrees Fahrenheit.” In only one instance did Theodore’s temperature exceed 102 degrees Fahrenheit, and in two instances his temperature was below 100 degrees Fahrenheit.
Humana denied a request for SCN1A sequencing genetic testing November 14, 2014. The denial was issued because this testing was deemed a non-medically necessary service. The specific reason cited in the phone call I received November 14, 2014 was the results of this SCN1A sequencing genetic testing would not alter the treatment or care of Theodore’s condition.
Theodore’s geneticist, Dr. Gunter Scharer, indicated the SCN1A sequencing genetic testing could alter the course of Theodore’s treatment, specifically providing a list of potential medications to avoid to prevent significant negative reactions. This is supported by the National Center for Biotechnology Information (NCBI), which states individuals with SCN1A-related seizure disorders should avoid “AEDs: carbamazepine, lamotrigine, and vigabatrin, which can induce or increase myoclonic seizures; phenytoin, which can induce choreoathetosis.”
Additionally, the NCBI states, “Use of the ketogenic diet to decrease seizure frequency has been beneficial in some affected individuals.” This means the results of this SCN1A sequencing genetic testing could, in fact, result in a course of treatment that is among the least expensive and least invasive accepted by the medical community.
It is apparent Theodore’s seizures are still a significant medical concern given that he unfortunately had another seizure two days after Humana issued the denial regarding this request. Since the results of the SCN1A sequencing genetic testing could significantly alter the course of Theodore’s medical care; AND alternative laboratory or clinical tests to definitively diagnosis the genetic disorder are unavailable; AND the SCN1A sequencing genetic testing is a clinically valid test, based on published peer-reviewed medical literature; AND Theodore has not previously received this genetic testing; AND the testing panel is for a specific gene deemed medically necessary to establish a diagnosis, we are asking for approval of this specific test.
Thank you for your assistance.
Again, thankfully, we were successful with the appeal. Although we didn't learn a diagnosis from this particular genetic test, we were then able to move onto the next level of testing. That next level of genetic exome sequencing was the test that gave us a diagnosis after nearly 2 years of searching.
My son, Theodore Blondheim, is a 16-month-old boy who is currently diagnosed with febrile seizures by his pediatric neurologist. However, Theodore’s seizures do not follow the typical pattern of febrile seizures, which is why Theodore was referred for genetic testing and consultation. Theodore has had five separate seizure episodes, two of which involved multiple seizures, with the most recent episode occurring November 16, 2014. According to the National Institute of Neurological Disorders and Stroke, “The majority of children with febrile seizures have rectal temperatures greater than 102 degrees Fahrenheit.” In only one instance did Theodore’s temperature exceed 102 degrees Fahrenheit, and in two instances his temperature was below 100 degrees Fahrenheit.
Humana denied a request for SCN1A sequencing genetic testing November 14, 2014. The denial was issued because this testing was deemed a non-medically necessary service. The specific reason cited in the phone call I received November 14, 2014 was the results of this SCN1A sequencing genetic testing would not alter the treatment or care of Theodore’s condition.
Theodore’s geneticist, Dr. Gunter Scharer, indicated the SCN1A sequencing genetic testing could alter the course of Theodore’s treatment, specifically providing a list of potential medications to avoid to prevent significant negative reactions. This is supported by the National Center for Biotechnology Information (NCBI), which states individuals with SCN1A-related seizure disorders should avoid “AEDs: carbamazepine, lamotrigine, and vigabatrin, which can induce or increase myoclonic seizures; phenytoin, which can induce choreoathetosis.”
Additionally, the NCBI states, “Use of the ketogenic diet to decrease seizure frequency has been beneficial in some affected individuals.” This means the results of this SCN1A sequencing genetic testing could, in fact, result in a course of treatment that is among the least expensive and least invasive accepted by the medical community.
It is apparent Theodore’s seizures are still a significant medical concern given that he unfortunately had another seizure two days after Humana issued the denial regarding this request. Since the results of the SCN1A sequencing genetic testing could significantly alter the course of Theodore’s medical care; AND alternative laboratory or clinical tests to definitively diagnosis the genetic disorder are unavailable; AND the SCN1A sequencing genetic testing is a clinically valid test, based on published peer-reviewed medical literature; AND Theodore has not previously received this genetic testing; AND the testing panel is for a specific gene deemed medically necessary to establish a diagnosis, we are asking for approval of this specific test.
Thank you for your assistance.
Again, thankfully, we were successful with the appeal. Although we didn't learn a diagnosis from this particular genetic test, we were then able to move onto the next level of testing. That next level of genetic exome sequencing was the test that gave us a diagnosis after nearly 2 years of searching.
I wanted to share these appeal for two reasons:
- First and foremost, don't give up hope if you receive a denial for services. Don't let an insurance company decide what is best for your child or loved one. Get mad, but then do something about it. There are processes within every insurance company to appeal. And there are, at least in Wisconsin, processes to appeal the insurance company's decision if their internal process doesn't yield a favorable result.
- By no means am I an expert after writing two appeals, but I'm more than happy to help others with this if they cannot find the support they need from their treatment team. I wanted to share the specific language I used to give others an idea of what worked for us and the general format we used. I would give credit to the original place online where I found an appeal to model ours after, but I don't recall what it is.
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