Speech therapy

[Whitney]

In a rather UHCLess fashion, Aetna has suddenly decided the in-home speech therapy should now be out-patient. Â*I guess they decided we needed to run around more.

I "appealed" on the phone and our ped is calling the appeals dept and the doc that "determined" it so. Â*

So my questions...has this happened to anyone before? Â*How did you successfully appeal it? Â*Without the trach (and given they are 3 now), it is harder to think of medical justifications for in-home. Â*My "feeble" reasons included Aidan's inability to adjust to new, unknown surroundings due to his sensory problems and continuity of care given he has had the ST for nearly 9 months now. Â*Alex gets ST under Medicaid so this is only affecting Aidan. Â*I appreciate any suggestions.

Thanks Â*http://www.tracheostomy.com/iB_html/non-cgi/emoticons/smile.gif

[Melisande]

Whitney,

I think the school should actually cover ST during the day. I think once they turn 3, outpatient therapy is usually more "traditional." EI services are more home based. I don't know if that's helpful or not. I'd love to get more ST for Donovan but we just get what the school provides right now. My insurance does not pay for much outpatient therapy anyway.

[lovemymak]

It's the same here. Keturah gets home based services until she turns 3 and then she gets turned over to the school district. It's sad. http://www.tracheostomy.com/iB_html/non-cgi/emoticons/sad.gif Thankfully, Keturah's not quite 2 yet, so she still has one more year to stay home. http://www.tracheostomy.com/iB_html/non-cgi/emoticons/wink.gif

[Whitney]

Melisande, they get minimal ST in school given budget restraints. We have things written in the IEP, but I am absolutely not confident in the services they will receive. Our private insurance has been paying for therapy all along. ECC hardly paid for anything. They wanted to send one therapist to do all the services (OT to do PT and ST). I told them thanks but no thanks and we used insurance instead.

I am beginning to think you are right about private insurance and "switching" to clinic settings...

[Melisande]

W-

EI services vary from state to state. I know that in MO they have discussed having one therapist do all therapies. That's fine for some kids, but most of our kids need A LOT of therapy. I haven't looked into additional speech for Donovan. I may just do that. I think we have a limit of like 20 visits per year for outpatient therapy with insurance though.

BTW- your avatar is scary!! http://www.tracheostomy.com/iB_html/non-cgi/emoticons/wow.gif http://www.tracheostomy.com/iB_html/non-cgi/emoticons/tongue.gif

[hcs_mom]

Hannah will switch to outpatient ST once she starts pre-school. They (both insurance and the hospital) allow at-home therapy for medically fragile, but I guess the logic is that if she is healthy enough to attend school then she is healthy enough to attend ST at the clinic.

Since we were able to get Hannah into the school for the deaf, I am confident in the ST she will get. They take hearing impaired as well as apraxic kids and they accept many kids who are not talking at all. This is why we pushed so hard to get her there.

I would have preferred to continue in-home therapy since we have been with this ST for 2 yrs now but she does not have any openings in her clinic schedule. However, I'm wondering if a new set of eyes and a new approach might be just what we need to get her talking...we'll see...

Jennie

[Judy]

We receive in home therapy for P.T., O.T. and S.T. and the 3 who are in school also receive it at school. We tried the
out patient therapies and found it unsatisfactory. It was actually Early Intervention who recommended the in home.
I will fight to keep ours in home.


Another good reason you might use for the in home is that
if he is taken out among the other children he could "catch" something that could mean hospitalization and end up costing the insurance companies much more than the in home therapy.

Good Luck and keep us posted. God Bless You All.


Judy and the 4 special Angels http://www.tracheostomy.com/iB_html/non-cgi/emoticons/angel.gif http://www.tracheostomy.com/iB_html/non-cgi/emoticons/wheelchair.gif http://www.tracheostomy.com/iB_html/non-cgi/emoticons/grouphug.gif