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Challenging Insurance on ABA

LALASEPT05LALASEPT05 member
in Special Needs

Hi All

I was curious if anyone has experience challenging an insurer for ABA coverage. I live in PA which has some mandated coverage. My insurance does cover speech and OT but they refused ABA on the grounds that it's educational and not medical. My HR department is willing to help me through the process of appealing but I wonder if this is a lost cause or is it even possible to appeal and win that decision?

Any advice or opinion would be helpful. DS is 3 and has and ASD diagnosis. Our county provided no behavioral support for him on their initial recommendation based on the fact that it's too restrictive which we are also contesting.

ABA was recommended as treatment by his Developmental Pediatrician. Thanks so much!

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Re: Challenging Insurance on ABA

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    LALASEPT05LALASEPT05 member
    Thanks Auntie...our plan is not self funded. I see that ABA is specifically mentioned under what does it cover and then the treatment requirements say 'must be medically necessary'. The insurance company has taken the stand that ABA is not a medical treatment rather and educational treatment. That would be what I would challenge and I am just not sure if I can even win that.
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    mamaj1220mamaj1220 member
    Hi sorry to just hop in here but I teach children with ASDs in NY and most families are running into this...have you gone to Medicare with the diagnosis as that's how many of our families found ABA services easier to get.
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