Insurance Appeal

Re: Insurance Appeal

• lite-bright member

  August 2012

  We thought we put together a pretty good appeal packet when insurance refused coverage for DD1's developmental evaluation. We had called ahead of time to check coverage and were still denied. 

  We had letters explaining the medical necessity of the evaluation, from both our pediatrician and the child psych who did the testing. We printed out documentation from both our plan's web site and EOB that specifically said "diagnosis covered" for autism. We indicated dates/times when we called the insurance company to check coverage and were told that it was indeed covered. We also looked up standard-of-care recommendations from at least one professional organization that deals with diagnosing ASD -- DH found those, and I don't remember which he used. We also found info on the insurance company's own site that detailed their recommendations for the autism diagnosis process. 

  Even with all that, sadly, it was still denied. We went through two appeals and their conclusion was that a far lower level of care -- a mere "psychiatric interview" instead of a full developmental evaluation -- was sufficient for diagnosis, and therefore we had to pay the full eval fee OOP. 

   

  
  
  DD1, 1/5/2008 ~~~ DD2, 3/17/2010

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