Diagnosis Destinations Apraxia Insurance

Insurance coverage for speech therapy is often provided but can require some legwork on your part.

Duration of treatment: If your policy specifies that therapy is a "short-term" benefit only, then the speech therapist must submit objectives and goals for short-term durations, i.e. two months or so at a time. Toward the end of the two month period, the therapist will submit a report of progress with renewed objectives and goals for the next two months (and so on).

Insurance Codes: The insurance paperwork filled out by the speech-language pathologist or pediatrician often requires a code number. Some codes are red flags for denials. A great code to use if you have a child with apraxia is 781.3 which is "lack of muscle coordination /coordination disorder." This shows a physical diagnosis, which is typically covered, versus a developmental diagnosis, which is typically not covered.

Website at which to Research Codes:
The code for apraxia is under ICD-9 Codes. Insurance Code Website

Also see Dr. Marilyn Agin's advice, "Insurance: Dealing with the Big Guys," at Children's Apraxia Net and read message number 263.

Denials and Appeals: If you are denied coverage for your child's speech and language therapy, always ask for the denial in writing and appeal the decision using the proper appeal procedure within your insurance company. Insurance companies count on consumers not appealing decisions. And the fact is that most people don't. All along the way, document your phone calls to the insurance company and also be sure to note whom you spoke with (first and last names) and what date you spoke to them. Keep brief notes about what each person told you. Documentation can be helpful for an appeal. In some states, even if (or regardless whether) you have exhausted appeal procedures within your insurance company, you can appeal to your state's insurance commission (and some state insurance commissions now allow the filing of complaints via the Web).

The Stroke Caregiver's Handbook advises that consumers not pay medical bills until you have exhausted the insurance appeals process: "One major insurance provider admitted that 98% of all judgments are reversed when appealed. Once you pay $1 of a bill, you are claiming full responsibility for that bill, and once you pay a doctor or hospital yourself, you will spend years trying to get that money back from the insurance company, if at all."

Which of the following best describes the reason for the insurance denial?:

Speech Therapy is Not Medically Necessary

Speech Therapy Must Result in Significant Improvement

Service Must be Rehabilitation for a Loss of Previously Attained Level of Functioning

Condition is of a Congenital Etiology

Pre-existing Conditions are not Covered

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

Articulation Disorders Are Not Covered

Public Schools are Responsible for Providing Speech Therapy for School-Aged Children

Other Tips

Ask questions & find answers at Speechville's new message board!