Cigna Insurance and ASD lack of coverage--grr!!

[kirstenb1]

Hi guys. I just got off the phone with Cigna. I had called to see why they were denying our 5 yr old's weekly OT and PT, after covering it for the last 6 mths. They said they deny treatment for developmental delays. I asked them if that included delays other than ASD, such as cerebral palsy. They said yes, they deny for that too!!!! Unbelievable!! Who is supposed to help these kids?

I will be appealing, but does anyone have advice? Now I'm glad I've called my state delegate and governor for the last 3 yrs to urge them to vote for autism insurance mandate coverage. But all these kids need help, not just ASD.

 

[disfan07]

I will preface this by saying that I despise health insurance companies and the way they are run so my opinion about this is very biased but...

Yeah...these insurance companies do not cover half of what they should be covering.

If the insurance companies would just cover these services for developmental delays, more and more children would be able to get the help they need and they would be able to reach their full potential....but that would cost these companies money so they don't want to cover it.

We have appealed denied claims probably about 5 times over the past 6 years. 3 have been for medications, 1 for an EP study and 1 for an MRI. We have won the appeals all 5 times. For the current issue with my PT (they deemed it "unnecessary" afte rthe first month of PT post- brain surgery and now I need to go back and they wont cover it...long story), my doctor is currently dealing with the insruance company because it relates to the surgery he performed but I don't know where it will go from here.

I don't know how Cigna deals with appeals so I can't really give you advice on how it will be handled but I wish you the best of luck and be prepared to fight for your child These insurance companies need to be forced to do what is right. Until there is a law that madates coverage for these children, the insurance companies wont voluntary cover it without a fight.

 

[brat]

Have you looked to see if she qualifies for any state/government programs? With my oldest we ran into the insurance not covering and then the hospital social worker directed us to a program that kicked in after fe had been in care for 6 months(something to do with long term vs temp with the delays).

 

[minkydog]

Unfortunately, this is typical. We have probably had at least 6 different health insurances over the last 16 years and NONE of them has paid a dime for Christian's routine PT, OT, or speech therapy. They will pay if there is a medical reason, like when he had vertigo and was falling down and walking into walls. But they would not pay for PT to teach him how to walk, how to sign, or how to eat from a spoon. Thankfully, he qualified for a special Medicaid voucher--some call it Katie Beckett waiver. If he didn't have Medicaid we would never have been able to afford ANY type of therapy.

Check in with your local county children's services. Maybe they have something to offer you that CIgna doesn't(or won't )

 

[kirstenb1]

Thanks y'all. Minky, that kills me about Christian. When I was talking to the rep I thought about kids with very clearcut physical delays, such as CP (not saying this is what Christian has). I was trying to determine if just ASD dx was getting us shut down or if it was more widespread.

She said anything that fell under Developmental Delays was an automatic denial. I told her, "I just do not know who is supposed to help these kids. This is what I thought we were paying for every month in premiums". Yet if we need Viagra someday, that is no problem!!! Agghhh!!

I'll check with our county, but it is very small and rural and not big on providing services.

 

[tw1nsmom]

First, insurance stinks.
Second, can I ask why the school isn't providing OT and PT? I'm assuming your child is in school. Even if he isn't, the schools administrates services once a child reaches 3 years old.

 

[TiggerStac]

We ran into them not covering speech. They will not cover it for a delay, but will cover it if you had it and then lost it. For example, if you had a stroke and then needed speech.

Thankfully in MA, it's covered by the state thru early intervention, not sure if it's that way every where else or not. So after Cigna denied it, early intervention was able to bill on.

 

[kirstenb1]

First, insurance stinks.
Second, can I ask why the school isn't providing OT and PT? I'm assuming your child is in school. Even if he isn't, the schools administrates services once a child reaches 3 years old.

That's a fair question. Here's my issue. They provide what is "educationally necessary". Which means they could in theory work on handwriting til the cows come home. But that doesn't address the underlying sensory issues. I would argue they interfere with her learning much more than any gross or fine motor weaknesses.

the first year in SPED, I thought it was enough, what the school provided. But when I really scrutinized what was going on, it wasn't enough. Educationally necessary is a whole different animal than socially necessary. Right now, in OT, we're all working on her asking for help. Zoe won't do it on her own. Social interactions are very overwhelming, and not considered educationally necessary. Yet, she won't be able to perform academically, unless she's able to raise her hand and ask for a repeat of directions, or some type of help. This whole situation has made me look very carefully at what our school provides.

On the whole they do a decent job. On the other hand, our family is blessed. We can just cut back in other areas and pay for therapy out of pocket. But what about families who can't?

 

[bookwormde]

Just remember the functional curriculum (social EF Speech, OT PT etc ) are concidered an equally important and part of education under IDEA.

bookwormde

 

[tw1nsmom]

That's a fair question. Here's my issue. They provide what is "educationally necessary". Which means they could in theory work on handwriting til the cows come home. But that doesn't address the underlying sensory issues. I would argue they interfere with her learning much more than any gross or fine motor weaknesses.

the first year in SPED, I thought it was enough, what the school provided. But when I really scrutinized what was going on, it wasn't enough. Educationally necessary is a whole different animal than socially necessary. Right now, in OT, we're all working on her asking for help. Zoe won't do it on her own. Social interactions are very overwhelming, and not considered educationally necessary. Yet, she won't be able to perform academically, unless she's able to raise her hand and ask for a repeat of directions, or some type of help. This whole situation has made me look very carefully at what our school provides.

On the whole they do a decent job. On the other hand, our family is blessed. We can just cut back in other areas and pay for therapy out of pocket. But what about families who can't?

Oh, I'm totally with you on this. I push for everything my DS needs in the school, but I don't rely on them providing it adequately. We pay out of pocket for many things,but...

Just remember the functional curriculum (social EF Speech, OT PT etc ) are concidered an equally important and part of education under IDEA.

bookwormde

I wanted to emphasize this. The social component of school is just as important as the mechanical/academic component. The OT may not be qualified to provide that component, but there is a social language component in speech, and social skills training through the school psychologist... You have a valid point that if she can't speak up and ask for help she won't get anywhere. Push that at the meetings.

Good luck. I know it isn't easy. DS is in 5th grade. I'd like to say it gets easier, but...