Insurance won't pay for PT???!

carmenlarue

 DS will be 10 months in a week and isn't crawling, nor is he pulling up or interested in it. He was evaluated by Early intervention per Pedi and it was suggested that he is performing at 6 months with Gross motor skills. So I had called my BCBSIL to find a PT which I found quickly, but the rep told me My husbands insurance will not pay for developmental delays, only will pay if the delay was caused by an accident or injury! How disappointing is this?! Im ready to get my baby the help he needs and they are saying no! Will I be able to do his therapy myself if we can't afford it? Does any one know a Pedi PT out there is Bump land? I need HELP. An guidance ladies?

ILoveBoys

I'm a lurker, but I have 3 kids and they crawled at 11mos, 12mos and 14mos respectively. Walked at 16/17mos (all 3). Babies are different. If there's nothing "wrong", enjoy the fact that you can put him down and he doesn't run away while you're back is turned.

I'm not sure how high on the growth chart your child is, but mine were all 100%'s, so their pedi attributed that to their lagging on their motor skills.

mamato3girls

Sahara78 said:

Does he not qualify for services through EI? Usually the state covers the cost.

This. My nephews had services through EI, or I think it was CDSA in their town. It was either completely free or on a sliding scale. I can't remember now.

rjeller32

From my child developmental classes in college (understand I am by no means a professional), this isn't something they will look into until the latter part of 15 months. Crawling isn't a milestone, and unless they can physically show any hip displacement or signs of bowed legs, they will not refer you anywhere or for testing until then. I believe standing is 18 months.

I understand the frustration, but I think your pedi is jumping the gun. Give your LO time. They all learn at their own pace.

st.augbride

If your doctor is concerned or feels there could be an issue with low muscle tone in the core, then have your doctor write a referral specifically stating why this is medically necessary and including an appropriate ICD-9 code. I have dealt with insurance junk for ds who started private PT at 6 months twice per week until he was walking at 18 months. If you suspect there is the need for PT, then trust your gut and find out exactly what the insurance needs to see on paper to get it approved, then bring that information to your ped and find a way to meet the requirements. You have to jump through some hoops, but you can usually find a way to get it covered or appeal their decision.

kjsmith9

Yeah insurance is horrendous.

I am a peds PT, and have lots of kiddos on my caseload that have developmental delay.  Honestly, I wouldn't be too concerned about him unless his tone was low and that was what was causing the delay.  Lots of kids don't do things until later, and are completely caught up at 2-3 years old.

That being said, ask your pediatrician if you think he would qualify for a diagnosis of "hypotonia."  If he does, insurance MAY pay for that.  However... I've come to find that if insurance knows there is a "developmental delay" reasoning (like they know his previous diagnosis that you called for involved a developmental issue), they are likely to deny claims.  A lot of my kids with developmental issues in the clinic only have 3 visits covered per calendar year.  

Any chance your insurance may have some changes when January 1 rolls around?  A lot of insurances where I live are going to start covering more of this in the new year (but not all of them).  Does he qualify for continued early intervention services?  Even if you had to pay a little out of pocket for this, it's certainly MUCH cheaper than seeing a PT in an outpatient clinic!

In the mean time, some things you can do with him:

- encourage supported standing activities (i.e., next to the furniture in the living room), limit time in the exersaucer/jumper if you use those... floor time is best!

- help him make transitions from laying down to sitting up (if he isn't doing that already) - put some pressure through his hips while he's side-lying and give him a hand to help pull up

- when he's on his belly, put your hands behind his feet and let him push in to you to show him what it feels like to scoot around

- on his back, do bicycle legs (alternating knees back and forth toward his chest)

As far as the pull to stand, some babies aren't strong enough, and some just aren't interested.  Put some of his favorite toys up on the couch, and start with him sitting on your lap on the floor.  Encourage him to stand from that halfway point first (rather than expecting him to go from the floor right away).  You can also use a small stool/bench/chair if you have that.

Hope some of that helps  Feel free to let me know if you have questions about other things - I'm happy to help as much as I can from online :P

ArmyWife114

mamato3girls said:

Sahara78 said:

Does he not qualify for services through EI? Usually the state covers the cost.

This. My nephews had services through EI, or I think it was CDSA in their town. It was either completely free or on a sliding scale. I can't remember now.

This.  My son has received A TON of great support from EI.  

hmontty

First of all, just do Early Intervention, if you qualify. It's free up to age two.

Second, I think it's too early to worry about that. If your child is not standing/walking at 18 months, then I would think about PT.

I am speaking from experience here. My DD, who has axial hypotonia (or low muscle tone in her core muscles), did not crawl until about 15-16 months...she started pulling up well after her first birthday. At 10 months, she was rolling around but not able to transition from lying to sitting herself and was not even doing commando yet.

At 18 months, she was not able to stand independently or walk (obviously). At that point, we took her to PT for a little encouragement, and she was walking six weeks later. She is now 2.5 and totally caught up.

Gross motor is the least important of the dimensions. Unless your child has some type of disability, I would not worry. Even low muscle tone, unless it's really severe, I wouldn't worry about too much (my daughter is "low normal" and is just really flexible now...but strong!). By the time kids are three, assuming health, they are all the same in gross motor anyway, no matter how they started out. You'd never be able to tell that my DD was a late walker.

carmenlarue

Thanks for the info ladies! This makes me feel better!

caymanianseminole

kjsmith9 said:

Yeah insurance is horrendous.

I am a peds PT, and have lots of kiddos on my caseload that have developmental delay.  Honestly, I wouldn't be too concerned about him unless his tone was low and that was what was causing the delay.  Lots of kids don't do things until later, and are completely caught up at 2-3 years old.

That being said, ask your pediatrician if you think he would qualify for a diagnosis of "hypotonia."  If he does, insurance MAY pay for that.  However... I've come to find that if insurance knows there is a "developmental delay" reasoning (like they know his previous diagnosis that you called for involved a developmental issue), they are likely to deny claims.  A lot of my kids with developmental issues in the clinic only have 3 visits covered per calendar year.  

Any chance your insurance may have some changes when January 1 rolls around?  A lot of insurances where I live are going to start covering more of this in the new year (but not all of them).  Does he qualify for continued early intervention services?  Even if you had to pay a little out of pocket for this, it's certainly MUCH cheaper than seeing a PT in an outpatient clinic!

In the mean time, some things you can do with him:

- encourage supported standing activities (i.e., next to the furniture in the living room), limit time in the exersaucer/jumper if you use those... floor time is best!

- help him make transitions from laying down to sitting up (if he isn't doing that already) - put some pressure through his hips while he's side-lying and give him a hand to help pull up

- when he's on his belly, put your hands behind his feet and let him push in to you to show him what it feels like to scoot around

- on his back, do bicycle legs (alternating knees back and forth toward his chest)

As far as the pull to stand, some babies aren't strong enough, and some just aren't interested.  Put some of his favorite toys up on the couch, and start with him sitting on your lap on the floor.  Encourage him to stand from that halfway point first (rather than expecting him to go from the floor right away).  You can also use a small stool/bench/chair if you have that.

Hope some of that helps  Feel free to let me know if you have questions about other things - I'm happy to help as much as I can from online :P

Everything she said!  Also see if the insurance will pay for it if it was labelled under "Delayed Milestones" instead of "Developmental Delay" - sometimes just a tweak in wording is all that's needed.

Also see if you can qualify for services or funding through EI in your area.

Good luck mama - this must be so stressful for you! Are there any other concerns or is it just the crawling? All children do things on their own pace so I'm sure your LO will get there on his own time!