OT for hypotonia not covered by insurance?

[Anonymous]

hi, all.

our DS has been in weekly OT for the past couple of months for help with his posture/upper body strength and fine motor skills. before he started therapy, I called the insurance company (Aetna PPO) to see whether he'd be covered. I asked whether he was covered for OT visits (which, in hindsight, maybe wasn't a detailed enough question). the rep told me he'd be covered for 30 visits per calendar year. we were going out of network, so I was told the insurance would pay for 70 percent of reasonable/customary after the deductible.

we proceeded with therapy. the diagnosis code (781.3) we were given by the therapist was for hypotonia/low muscle tone.

thinking we'd be covered, we waited several visits before making a claim, so we could send several claims at once. big mistake.

we got notice that DS is not covered. I just called Aetna and the rep told me DS is not covered for OT for developmental delay. he said the diagnosis code the OT used was for "lack of coordination," which is not covered. so is 781.3 hypotonia or lack of coordination? I'm totally confused and worried that we will have to pay for all the OT ourselves. it's quite a bit of money!

I put a call into the therapist to see what advice she might give and whether she's willing to call Aetna to try to straighten things out (if they CAN be straightened out).

looking for any insight. thanks so much.

[Anonymous]

This is 781.3:

781.3 Lack of coordination

Ataxia NOS
Muscular incoordination

Excludes:
ataxic gait (781.2)
cerebellar ataxia (334.0-334.9)
difficulty in walking (719.7)
vertigo NOS (780.4)

[Anonymous]

Should be just as easy as having the OT correct the diagnosis code and resubmit the bill. This is a pretty common mistake and easy to fix.

[Anonymous]

When we had Aetna PPO a few years ago, the ONLY Ot they would cover under our policy was basically if the person needed to re-learn life skills after a catastrophic event like a stroke or a car accident.

Everything else was excluded.

OP, have you looked up your policy language? Our DS had basic low tone, too, but no other 'big bad' diagnosis.

Aetna sucks ass, by the way.

[Anonymous]

ps, a lot of families have to "pay for all the OT themselves," I'm finding out.

[Anonymous]

I know just about nothing is covered in our insurance. Call Aetna and have them send you all the rules for coverage and all the addendums (if any). I found some of the addendums actually made things covered that were not covered in the original document. I can only speculate that families went to court and the court ruled in favor of the client and this is what is now covered.

After you get that, check and read everything. If you appeal and they deny coverage, you can always appeal to your state insurance agency.

[Anonymous]

We have United Healthcare and have been in your situation.
My son is 2 with hypotonia and receiving OT in a private facility.

It took me over a year to get United healthcare to pay for a portion of his services.
It all depends on who you speak to within the insurance company.

We called for months and spoke to hundereds of different people.
We finally found someone who would approve of the therapy.

My advice is to keep trying until you find someone who will listen.
Ask your therapist to write a letter to the insurance company explaining why the
services are needed.

Good luck.

[Anonymous]

Anonymous wrote:We have United Healthcare and have been in your situation.
My son is 2 with hypotonia and receiving OT in a private facility.

It took me over a year to get United healthcare to pay for a portion of his services.
It all depends on who you speak to within the insurance company.

We called for months and spoke to hundereds of different people.
We finally found someone who would approve of the therapy.

My advice is to keep trying until you find someone who will listen.
Ask your therapist to write a letter to the insurance company explaining why the
services are needed.

Good luck.

I do billing for an OT. This is great advice.

[Anonymous]

We have United Healthcare and have been in your situation.
My son is 2 with hypotonia and receiving OT in a private facility.

It took me over a year to get United healthcare to pay for a portion of his services.
It all depends on who you speak to within the insurance company.

We called for months and spoke to hundereds of different people.
We finally found someone who would approve of the therapy.

My advice is to keep trying until you find someone who will listen.
Ask your therapist to write a letter to the insurance company explaining why the
services are needed.

Good luck.


I do billing for an OT. This is great advice.

But is it practical? Not many parents have the time to speak to "hundreds" of different people, certainly not working parents.

[Anonymous]

It also helps to get a letter from your doctor and/or developmental ped. that says the OT is "medically necessary." I concur that you need to be very persistent. Some things that worked...1. Get a letter from your doctor and/or developmental ped. that says the OT is "medically necessary." 2. Have the therapist even if you have to pay her/him to write a lengthy report about why your DC needs the therapy. You cannot provide too much information in this instance. The reports will be forwarded to peer review. If they deny, keep sending information. You want to keep the dialogue open so you don't have to appeal. Once it goes to appeal, it's much more difficult to get the claims approved. 3. Call daily (yes, it was a huge amount of time, but it was for thousands of dollars. 4. Submit each claim/date of service (DOS) separately. Eventually one may get processed. Larger insurance companies such as Aetna don't approve all its claims manually. Most are done by a computer. One may be more helpful than the other. 3. Once a claim gets processed, call customer service and have them link all other claims to that DOS. Good luck! We've had a number of insurance companies over the past five years, and I had to fight each of them for reimbursement. Eventually, we were reimbursed. Fortunately, we were in the position to float the costs until that happened.

[Anonymous]

Our DS was diagnosed with hypotonia and we ended up paying for ot out of pocket. Our ins company denied the claim even after the ot and ped wrote letters saying it was developmentally necessary. They basically told us unless he was diagnosed with a disease or needed the therapy as a result of an accident they would not cover it. It was very frustrating.

[Anonymous]

This is outrageous. Maybe the association for occupational therapists needs to get a good lobbying group going. It seems that their profession would benefit from having insurance plans recognize the value of their services in broader contexts. Parents are wiped out --maybe someone else can pick up the slack.

[Anonymous]

Is there an appeal process, OP? We were denied coverage for speech therapy, and we appealed the decision. It took about two years, no kidding. And we lost, by the way, but at least there was a process!! Worthless insurance co's!! Long live Obama's new health care plan!

[Anonymous]

We call our insurance carefirst PPO which currently pays for no therapies for my son because he is under 3 "the dark empire" You can imagine what we called our case manager who my husband recently fired

[Anonymous]

OP, if your insurance is a benefit of yours or your child's other parent's employment, most likely there is an appeal process. The appeal process should be spelled out in your documents and the deadline should be spelled out as well. If you miss an appeal deadline, you can be completely out of luck with respect to getting the decision reversed and the law will be on the insurance company's side. Sometimes carriers waive the deadlines, but they are not obligated to, so don't assume yours will.