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Is it worth appealing to insurance?

wellfleet04wellfleet04 member
in Special Needs

We just got a notice that DD's weekly OT for gravitational insecurity is no longer going to be covered by our insurance (boo!).  The letter says we can appeal, but I'm wondering if it's even worth trying. I really love her OT, and she has made AMAZING progress, but she's over 3 so I could also switch her from private therapy to therapy through the school system assuming she qualifies.  I'd really like to stay where we are, though.  So...do people ever have luck with the appeals, or it is an exercise in futility?  Thanks!

 EDITED:  I guess I worded that wrong.  I am going to try, I guess I am just wondering whether it's one of those things where they have to SAY you can appeal, but they rarely ever DO reverse the decision.  I'm mostly trying to gauge whether we have a real shot at staying where we are with coverage via an appeal, or I should move forward with the eval process with the school system (which is long, evaluates her for things she doesn't need, like speech, and would mean she'd have to miss 6 days of preschool which she loves). 

She was denied based on a "physician's review" saying that her need isn't great enough to continue coverage. Which is why I'm skeptical whether an appeal will work.

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Re: Is it worth appealing to insurance?

  • akimboakimbo
    absolutely appeal - why wouldn't you try? your OT should be able to help you with this too. Were you denied because you reached a cap?
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  • akimboakimbo
    sorry - that sounded snarky -  the process isn't too bad, but if you don't try the answer will always be no.  You've established a rapport with this OT and there's been great progress....by all means keep it up if you can.
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  • MaddimomMaddimom
    Butting in.... Is the insurance company stating the OT is not going to be covered or the provider? I used to work in the appeals department at a large health insurance company so I can give you some tips.... Send me a PM if you wanna chat
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  • Florak8Florak8

    We appealed on something that was an exclusion on our policy-- they never budged. However, I would speak with your physician and let them know what happened. If something used to be covered, and your policy did not change, then I would think there is a good chance you get that covered again.

    It's all a game-- who will give up first. Good luck! 

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  • wellfleet04wellfleet04 member

    Thanks, auntie.  The letter seems to say that the policy (we suspect that DH's new HR rep just changed their insurance) covers OT for injury, so I suspect it is your third paragraph that is going on.  Not exactly sure.  I am a total novice at navigating the insurance game, so I feel like I'm not sure how to best resubmit.  I will talk to her OT about it on Tuesday.

    Re the evaluation, I have NO IDEA why our district does it this way, but you have to have them evaluated at their facility for SIX WEEKS, only on Mondays, from 9-12.  She's had several comprehensive evals before, through EI and through the place where we now get private OT (they also do PT and speech), so I'm not thinking they'll find anything "new", though I guess it's always possible.  

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  • skittles_123skittles_123 member

    I would definitely appeal, but don't get your hopes up. It depends on your policy and state laws, etc. We lost all appeals for all-OT, ST and ABA (ds has autism), through my dh self-funded plan. Self-funded can do whatever the heck they want. My dh works for one of the largest companies in the country and they still did crap for us, it wouldn't have cost them much in the long run, as big as they are, it was completely irritating and frustrating. Anyway, enough with my vent. We have a private policy now and we have no issues.

    Auntie, I did have a question for you. Didn't the new federal laws prohibit lifetime limits?

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  • skittles_123skittles_123 member
    Yeah I knew about visit numbers as my sons policy has incredibly low limits for visits for OT and ST. But dollar amts were limitless. We are switching insurances to my employer during open enrollment which abides by KY laws, which prohibits limits on visits starting in 2011 but has a cap of $30K per year, but ds starting school in the fall of 2011, he won't use it all up.
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