Reason for Denial: "Service must be rehabilitation for a loss of previously attained level of functioning (or Condition is of a Congenital Etiology or Pre-existing conditions are not covered)"
Essentially this denial is stating that "habilitative" services are not a covered benefit, that children, who are developing speech, are not provided speech therapy benefits, while "rehabilitative" services are a covered benefit for adults, who have already developed speech. (Or that your child must have had some speech, then lost it, and speech therapy would bring him or her back up to the level of speech prior to the "loss".)
Speech and language skills are not limited to vocal expression. The foundations of speech are being developed before a child is born. Some states have laws that prohibit insurance companies from discriminating on the basis of age; if an adult is receiving covered speech services for the same symptoms, then a child's therapy must also be covered. Investigate your state's laws concerning medical insurance. This link will guide you to resources at your state government: http://www.makingakilling.org/appendix2.html
In addition, the United States' federal rehabilitation services provision of 42 USC 300 e-1(1), federal required benefits for physical, speech,
and occupational therapies, and HCFA's interpretation of the federal provision include "habilitation" services under "rehabilitation services".
The inclusion of coverage of habilitation services is also consistent with HCFA's administration of federally qualified HMOs.
If you receive a denial of services on this basis, provide your insurance company or HMO with documentation to show either why habilitative services should be covered when rehabilitative services are covered (optional documentation to include: the United States Code referenced in the paragraph above)
and/or information to demonstrate that your child's speech difficulty manifested at some specific point in time (i.e. after chronic ear infections,
after an incidence of anoxia, after a head injury, etc. -- detail the frequency, duration, and seriousness of any such incident), therefore,
speech therapy is rehabilitative in nature.
Speechville Express
is a resource for families, educators, and medical professionals, offering
information about language development in children, helping those who
care for toddlers and young children who are late talkers, and connecting
you with others who have been down this road. Language disorders and
communication impairments included are apraxia, stuttering, pervasive
developmental disorder, dysarthria, and aphasia, among others.
aphasia
