Help with Insurance Coverage for Communication Disorders









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Diagnosis Destinations

Apraxia

Appealing Insurance Denials

Apraxia is "Developmental". "Developmental delays" are not Covered.

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

One of the most important things to do when applying for insurance coverage of apraxia-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 Apraxia of Speech" or "Developmental Verbal Dyspraxia." While these terms are common in apraxia and 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 Apraxia" is not the same as "developmental delay," nor may he or she know that "Developmental Apraxia" is used primarily to distinguish the condition from "Acquired Apraxia" (the loss of speech caused by a known incident of stroke or other brain trauma). The therapist should use a term such as "apraxia of speech," "oral motor planning disorder," or "speech motor disorder."

The insurance company might also be confusing apraxia of speech 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. Apraxia is not a "developmental disability," though apraxia can co-occur, in some children, with a developmental disability. Regardless of whether or not a child is developmentally disabled, in addition to having apraxia of speech, the insurance company should not deny the claim on the basis of the developmental disability, if oral motor speech disorders 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 Apraxia of Speech as "developmental delay" (code 315.9) or "developmental speech or language" (code 315.31). Codes to use are: a neurological code (codes 340 - 349) or coordination disorder (code 315.4). 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 apraxia of speech is not a developmental delay of speech. Apraxia of speech is disordered speech, speech that is not following a typical developmental path, whereas a child with developmentally delayed speech has typical speech patterns, albeit those of a younger child. Sometimes describing apraxia of speech as a neurological disorder or condition seems to help. Therefore here is a quote about the nature of apraxia from a well-known speech-language pathologist who specializes in apraxia of speech in children, Megan Hodge,

"...This disability has a neurological basis of unknown origin. It may reflect neuro-anatomical/physiological differences that are inherited (see Hurst, Baraitser, Auger, Graham, and Norell, 1990; Shriberg, 1993) or damage that occurs pre- or postnatally during the period of speech development (Crary, 1984; Marquardt and Sussman, 1991)..."