Insurance won't pay

by Gina
(Massachusetts)

I finally got my insurance to pay for the evaluation but may not cover treatment because they don't cover sensory integration dysfunction. This really gets me mad because if OT can help why won't they give it to him? My son also has mild low muscle tone. Do you think he might be able to get help for that??? I am trying to figure out how I can still manage getting him treatment somehow but maybe calling it something else. Has anyone else had to face this issue? What have you done to get your child help if you can not afford paying out of pocket? He does get OT services at school but not as much as I think he needs.

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Jan 15, 2014
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Im starting to see denials.
by: Zack

I am a(COTA) certified occupational therapy assistant at an outpatient rehab facility in Texas. At the end of 2013 i recieved a denial letter from tricare on an autistic clt saying they did not cover sensory integration work and that it was investigational. The insurance company wanted all reimbursements paid back after 1 1/2 yrs. Since then i have recieved a denial letter from medicaid and cigna on 2 other clts. We have decided to dumb down our documentation and not use the word sensory in our notes. Be carefull w/treating diagnosis used 782.0 skin sensation disturbance was the code used that was denied on 2 of our clts. It is a shame that insurance companies are denying what special kids need the most.

Sep 02, 2012
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insurance coverage
by: Julie

My son is in the process of being diagnosed with SPD. At his OT evaulation, the therapist asked what insurance carrier we have because many won't cover OT for sensory issues. We "lucked out" so to speak, our insurance will cover it. Even for low muscle tone, she said some insurances will only cover PT, not OT.

Aug 03, 2012
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same thing
by: Emily Martin

I'm actually being told by our OT that the insurance won't pay for treatment - they had no issues with the claim for the evaluation at all. The insurance company told me when I called that they will pay for the codes used for the evaluation if the same are used for the therapy. However, the doctor's office is telling me something else!

I need some advice on the subject!

Dec 04, 2010
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We Won Our Six Month Battle
by: Jewel

Hello - I don't know how your battle is going, but I just won a six month battle with our insurer to cover our son's Sensory Integration OT. If you still need help, I can suggest to you a few of the things that I tried. It was a long, hard, emotionally draining process...but four denials and siz months later, my husband and I are only obligated for his weekly $25 co-pay.

Sep 15, 2010
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Insurance games
by: Christina

Most medical professionals know ways around these things - it's all about how they code it when they send it to the insurance company. Just like the person before me said, talk with them, explain the situation, and they should be able to figure something out. Good luck!

Sep 02, 2010
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Re: Insurance won't pay
by: Anonymous

You should ask the professionals who diagnosed him with SPD how it can be presented in way that the insurance company cannot deny. The insurance companies will reject anything labeled "SPD". Perhaps if you break down the diagnosis into something more specific, then they will have to pay. Although my child's issues were clearly sensory related, we used the term "fine motor delay" to get coverage. At least that got us through the door!

Also, your son should be eligible for physical therapy if he is diagnosed low tone.

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