insurance, OT, and SPD

[Rose-Roget]

I know all insurance companies are different. I'm wondering whether people have had success getting coverage for OT services for their kiddos with SPD? I just took it for granted that we would be covered since we have an number of OT visits allowable per year, a doctor's referral, and OT report to document need. So far the claims have been denied, and I'm starting to freak out because we can't afford OOP.

Have other people had success getting coverage when only SPD is a factor - no ASD or other disability with SPD as a player? Is it because SPD is not in the DSM-IV? Would it help to get him verified ADHD - I'm not sure that opens any other doors, and I don't want the insurance to say the treatment for that would be drugs (can they do that?). I'm not really sure it is ADHD - his difficulties really can be traced back to SPD.

I'm not very insurance savvy. Thanks for any help or advice.

[beachbaby]

Our insurance (BCBS) covers OT for SPD. We don't have a dx of autism or adhd. The OT used 'neurological neglect' as the diagnosis. She explained that was the way to get it covered. I guess it's a medical term that's accepted by the insurance companies. I'd ask your OT about how they can code it so that your insurance will accept it. I think you can also file an appeal to the insurance company. I'm not insurance savvy either, so maybe someone else can chime in with more. Hope this helps a little.

[KCMichigan]

Originally Posted by beachbaby

Our insurance (BCBS) covers OT for SPD. We don't have a dx of autism or adhd. The OT used 'neurological neglect' as the diagnosis. She explained that was the way to get it covered. I guess it's a medical term that's accepted by the insurance companies. I'd ask your OT about how they can code it so that your insurance will accept it. I think you can also file an appeal to the insurance company. I'm not insurance savvy either, so maybe someone else can chime in with more. Hope this helps a little.

BCBS also covered us for OT. My DD had a PD_NOS and mild CP dx tough on top of SPD. but all the OT was for was sensory issues....she went to PT for the CP....her fine motor skills were great!

I would talk to the Dr that suggested OT and/or go through your EI or schools (DD also got OT/PT through the schools).