Funding For SI Therapy

by Brian Mengini
(Schwenksville, Pa )

Hello... my 5 yo son was diagnosed in Feb '06 with a mixed expressive receptive speech disorder, apraxia, SID, and now hypotonia. We cannot get, as I am sure you know, treatment covered by our insurance. The place we found and love for SPD treatment is $90.00 per session. What funding options and resources are out there?


The SPD Help Line Answers...

Ah, this is a very common question from parents. And a very serious problem for sure. But, I will say, I do have hope in YOUR particular situation. Why? Because your son carries multiple diagnoses. This, as far as insurance and treatment goes anyway, is a good thing.

Let me explain. You are correct about Sensory Integrative OT not being covered by insurance, IF that is the specific diagnosis the Occupational Therapist, or clinic, puts down when submitting to the insurance company. We are still advocating for this to change. Some progress has been made, but we do have quite a way to go. You can read more about where things stand now on getting SPD into medical diagnostic manuals in this article from a back issue of my monthly newsletter, Inclusion Of SPD In The DSM V.

That is the bad news. The good news? Your son's multiple diagnoses should definitely allow room for insurance reimbursement if the codes are submitted correctly for some of the other issues he would be addressing in OT. For example, a reimbursable condition should be hypotonia. This should get him PT, OT, speech, etc. and is closely connected to his SPD. The SPD, should be able to be addressed in OT while addressing his other issues. It is a necessary way around the system. It is indeed ethical, as we should be treating the whole body, not just one part, one issue at a time. This treatment can EASILY be combined with his treatment for the other diagnoses you mentioned.

That said... I am wondering... how did you find out your insurance will not cover therapy? Did YOU talk to the insurance company, did the facility you went to do it? Who talked to them and what did they say? Were they only planning to deny OT for the SPD or was it being denied for other diagnoses? What type of insurance do you have? Is it "regular" insurance, or are you talking something like Medicaid? If it is "regular insurance" there should be ways around this.

I would have another discussion with the therapist or facility AND your insurance company regarding coverage for the various diagnoses and, specifically, take a look at and use Commonly Used Diagnostic Codes For SPD Insurance Reimbursement. If the clinic or Occupational Therapist cannot find codes that will be billable, with the particular diagnoses YOUR son has, I would RUN to another therapist. This should be able to be worked through so your son can get the treatment he needs.

Is it easy for SPD? No way. If that is the ONLY thing being treated it is indeed harder to find diagnostic codes that are acceptable to insurance companies, but many do. I truly hope you can work with the people you have, or find another facility for treatment if they are not willing to try to work this out regarding the insurance reimbursement. The kids come first! Money is second. I know any facility is indeed a business, but I would not want my child treated at a facility that is not willing to work with me, discuss this, or address this in a way that will make therapy possible (I hope they DIDN'T do that to you). It makes me so very sad when people cannot afford treatment, yet their children need it so bad. There is a way... we just have to find it, ok?

OK, all that said, one last thing to consider is the actual money issue. IF you have a good therapist, treatment will be intensive, but for a fairly short duration. This treatment should not have to go on for years. Will he need to see an OT every so often after things get going on the right track and he has a few months under his belt? Probably. But those will be "tune ups" as his system changes. So... the question lies with the parents. How can they actually afford the treatment if there is not going to be insurance reimbursement for some reason?

Well, I challenge you to think about the "costs". The cost to your child if this goes untreated. The cost to your family if this goes untreated. Not monitary costs... emotional costs. We, as parents, make sacrifices for our kids... that is what we do. And if it means giving up those dinners out, or shopping at cheaper stores, or dipping into our savings, etc. for a few months, then we need to try to make this work, don't we? For our kids? For them? There are usually (not always, but usually) ways we can scale back for a few months or as much as a year, for the sake of our children.

I know people who have become very creative in changing their priorities and dealing with the sacrifices they must make for their children. If the SPD is "bad enough", they will do it, whatever it takes, because the cost of NOT doing it is too great. You know? Think about any ways you or your family (extended family included) could contribute to the therapy fund. There are ways, if there is no possibility for insurance reimbursement (but, there usually is-- not easy to find sometimes, but there is), then WE must make a sacrifice somewhere, and we CAN. It comes down to priorities, creativity, and reaching out. Here is an article you might find helpful... Financial Help For Sensory Products And Treatment.

This said, please understand I am NOT saying you don't have your priorities straight. What I AM saying is that sometimes we just have to dig a little deeper for the answers. Start with the three articles I recommended, while also talking with the OT or facility and the insurance company to see if something, anything, can be worked out. If the sole financial burden will rest with your family, then you may have to make some big decisions and careful planning. I urge you to do everything in your power to get your son the therapy he needs. You will be so glad you did, as will he. He will thank you one day, in some way. He will. And you will reap the rewards of a better future with him and your family.

Be strong and fight for your son, ok? Fight for reimbursement from the insurance company. YOU deserve it and so does HE!

Let me know if you still run into brick walls or if you are indeed successful in your search for help. I would love some feedback regarding this. It is a huge problem and we definitely need to keep shouting about it. We must talk about the struggles AND the solutions. We must be heard!!

Anyone else have some tips on getting therapy covered through insurance? Any ideas, suggestions about effective ways to get through this maze? Any input? Let us know.

Have YOU been through a similar experience? What did you do? Can you share your story and ideas with us? We would greatly appreciate it!

Take good care.

Michele Mitchell

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Oct 02, 2007
funding for therapies
by: Laura

I live in California and my son's OT and speech therapies are funded through the public school system once he turns 3 years old.

Before the age of 3, we have Regional Centers which provide early intervention services (funding for therapies).

Maybe explore similar services in your area?

Good luck!

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