Diagnosis Destinations Aphasia Insurance Aphasia is "Developmental","Developmental delays" are not Covered

Reason for Denial: "Aphasia is developmental. Developmental delays are not covered."

One of the most important things to do when applying for insurance coverage of child-related therapy is to ensure that the evaluator (that is, the speech-language pathologist) does not use the word "developmental" in his or her report, as in "Developmental Aphasia". While these terms are common in speech therapy literature, for many families these phrases have been the sole cause of denials of insurance coverage. Insurance companies' claims evaluators see the word "developmental" and think, "developmental delay." Most insurance companies and HMOs do not see it as their responsibility to pay for speech therapy if speech is developmentally delayed, which they interpret to mean "will improve with time, with or without treatment". The person who is denying claims often does not know that "Developmental Aphasia" is not the same as "developmental delay," nor may he or she know that "Developmental Aphasia" is used primarily to distinguish the condition from that which occurs in adults after a stroke (or similar incident).

The insurance company might also be confusing aphasia with a "developmental disability". The United States government's definition of "developmental disability" requires that the disability be a mental and/or physical impairment, manifest before the individual is 22 years old, will likely continue indefinitely, results in substantial functional limitations in 3 or more major life activities, and will necessitate special services and supports of either lifelong or extended duration. Aphasia is not a "developmental disability," though aphasia can co-occur, in some children, with a developmental disability. Regardless of whether or not a child is developmentally disabled, in addition to having aphasia, the insurance company should not deny the claim on the basis of the developmental disability, if speech therapy would otherwise be covered.

Therapists and doctors use diagnostic codes for insurance purposes. Again, the provider should not code a diagnosis for a child with aphasia as "developmental delay" (code 315.9) or "developmental speech or language" (code 315.31). Acceptable codes to use: a neurological code (codes 340 - 349). It is worth your while to ask the therapist or doctor (depending on if you need your physician's referral) what diagnostic code they will use in the report or referral.

If you have already received a denial of insurance because of the "developmental" confusion, you will need to provide documentation to your insurance company or HMO demonstrating that aphasia is not a developmental delay. Read through aphasia citations in the literature for definitions describing aphasia as a neurological condition and request that your child's speech pathologist provide you with further references.

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