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Help Navigating Insurance Denial VA

VAJuneBride07VAJuneBride07
in Special Needs
I'm at a bit of a loss. After a year of EI services, we got a denial of an appeal because inhome services weren't considered medically necessary. BUT Virginia requires inhome or natural environment services. The amt for 1/2 the year is about 2000, so I'm guessing it will be about 4000 for the entire year. I'd really like to appeal this but I don't know where to begin. Does anyone have any experience with this?
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Re: Help Navigating Insurance Denial VA

  • realisticdreamsrealisticdreams member
    imageVAJuneBride07:
    I'm at a bit of a loss. After a year of EI services, we got a denial of an appeal because inhome services weren't considered medically necessary. BUT Virginia requires inhome or natural environment services. The amt for 1/2 the year is about 2000, so I'm guessing it will be about 4000 for the entire year. I'd really like to appeal this but I don't know where to begin. Does anyone have any experience with this?


    It may be county specific, so don't take my word for it.  But, we live in VA & our insurance almost always denies EI, even our old insurance did.  They have an income chart with monthly cap as well.  So if you don't have insurance (in fact now, new rules say you can choose if you WANT to bill your insurance--this just started) or just use the monthly cap.  Monthly cap goes by your TAXABLE income (which is significantly less than your gross/adjusted gross).  

    If you are in Alexandria I will look online a little bit and see if I can come up with any helpful info.  But you need to ask them about their monthly caps for when insurance does not pay, and go from there.

    ETA: It's called a sliding fee scale 
    DD1(4):VSD & PFO (Closed!), Prenatal stroke, Mild CP, Delayed pyloric opening/reflux, Brachycephaly & Plagiocephaly, Sacral lipoma, Tethered spinal cord, Compound heterozygous MTHFR, Neurogenic bladder, Urinary retention & dyssynergia, incomplete emptying, enlarged Bladder with Poor Muscle Tone, EDS-Type 3. Mito-Disorder has been mentioned

    DD2(2.5): Late term premie due to PTL, low fluid & IUGR, Reflux, delayed visual maturation, compound heteroygous MTHFR, PFAPA, Bilateral kidney reflux, Transient hypogammaglobulinemia, EDS-Type 3


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  • VAJuneBride07VAJuneBride07
    Thanks!  We are well under the monthly cap for our family - which isn't a bad problem to have.  I realize we're incredibly fortunate in that respect.  I do think insurance should pay this though given that the state law mandates that insurance unwritten in VA cover developmental therapy up to $5000/year and my husband's policy is indeed underwritten in VA.  It's also incredibly frustrating that we're in a better position than most to navigate this (I'm an attorney and I've helped clients navigate SSI/SSDI and Medicaid) and I'm still at a loss as to where to begin. 
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  • realisticdreamsrealisticdreams member
    imageVAJuneBride07:
    Thanks!  We are well under the monthly cap for our family - which isn't a bad problem to have.  I realize we're incredibly fortunate in that respect.  I do think insurance should pay this though given that the state law mandates that insurance unwritten in VA cover developmental therapy up to $5000/year and my husband's policy is indeed underwritten in VA.  It's also incredibly frustrating that we're in a better position than most to navigate this (I'm an attorney and I've helped clients navigate SSI/SSDI and Medicaid) and I'm still at a loss as to where to begin. 


    Well, for starters depending your childs diagnosis you should look into the medicaid waiver.  I know some children who get approved very easily whereas others who should qualify don't.  But that is regardless of income and would give you medicaid as secondary which would automatically pay for EI.

    As for appeals..I have done a couple appeals, all of which were never approved. So I don't really know for sure, does the EI dept have someone who can help you with it?  Do they cover outpatient PT?  Could you give them the cost difference and say that you actually saved them money by using EI instead of outpatient therapy?

    DD1(4):VSD & PFO (Closed!), Prenatal stroke, Mild CP, Delayed pyloric opening/reflux, Brachycephaly & Plagiocephaly, Sacral lipoma, Tethered spinal cord, Compound heterozygous MTHFR, Neurogenic bladder, Urinary retention & dyssynergia, incomplete emptying, enlarged Bladder with Poor Muscle Tone, EDS-Type 3. Mito-Disorder has been mentioned

    DD2(2.5): Late term premie due to PTL, low fluid & IUGR, Reflux, delayed visual maturation, compound heteroygous MTHFR, PFAPA, Bilateral kidney reflux, Transient hypogammaglobulinemia, EDS-Type 3


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