Great news! My 8 year old son’s school district agreed that he will learn best in an alternative school. We’re happy. However, our independent testing expedited the decision. He is dyslexic and has ADD.
The cognitive testing cost $2,500 and Innovative Resource Group (the behavioral health company Aetna PPO uses) has denied the claim via a final review process. “While the diagnosis of ADHD is noted, the evaluation clearly appears to have focused on learning related issues. Request denied due to failure to meet medical necessity criteria.” The are denying the claim because they say the intent was to determine deducational problems. The diagnoses as a result of the testing was ADHD and dyslexia.
The appeal denial says to consult with my employers benefits administrator to determine if other appeal options are available.
ANY WORDS OF WISDOM FOR APPROACHING MY EMPLOYER?
Thanks in advance.
Re: Reimbursement For Cognitive Testing By A Psychologist
What state are you in? The rules vary by state.
In New Jersey you are entitled to an appeal by a medical review board. I think this is true in other states but I believe that the time frames are different in how quickly they must respond.
In N.J. once you have gone through the insurance companies medical review board you have the right to have an outside M.D. review the case. So you have 2 chances to beat this.
Find out from your insurance company who a medical review appeal is sent too.
Get a letter from your primary M.D. (not the one who did the test) stating why this consult is a medical neccessity. Write a letter yourself as to why you believe this was medical and not developmental. The key is that your child’s problem is medical and not developmental. I believe ADD is considered medical but am not 100% sure on that.
Send it in for medical review.
Let me know what state you are in and I can probably send you more info.
Re: Reimbursement For Cognitive Testing By A Psychologist
I am in the state of Illinois.
Any information you can provide is greatly appreciated!
Re: Reimbursement For Cognitive Testing By A Psychologist
4th,
I sent you an email with a link to your states office of health insurance consumer rights division. They are pretty similar throughout the country.
Hope it helps.
Linda F
Can you show any speech and language based deficits through the testing? Something that shows he has problems with communicating, perhaps his ADHD has caused him problems with interacting with his peers (pragmatics) and this has caused him psychological stress? I know PPO’s have covered my daughters private speech and language therapy but she also has a hearing loss. They also covered her seeing a specialist for ADHD as she wasn’t progressing academically and socially.
You have to prove your case medically that the testing showed more than just educational deficits and going with either a mental health or speech and language issue may prove it to be a medical necessity. Of course the neuropsyche would have to do some more explaining showing the medical necessity, I am sure they would help with this as well.