Wednesday, April 1

What works for us Wednesday

We recently learned that our medical insurance denied Tommy's speech therapy service request. Grrrr. When I had called the company few weeks back and was glad to hear they had approved our request for speech therapy...... I was overjoyed. That turned to extreme frustration when I learned they had altered the request to a single visit evaluation. Once the evaluation was done, then they issued a denial for our 40 visit request. Grrr.

Today, we filed an appeal to the decision. And that is "What Works for us Wednesday". I'm not sure if my point to this post is to show you how to write an appeal. Or if this post is meant to publicly state that UHC denies speech therapy services to children with Down syndrome. Or perhaps this post is simply meant to let UHC the "letter is in the mail" as they so nicely let me know when they refused to talk about it further. Hey, UHC, the letter is in the mail. And it will be graciously signed by our loving team members, SLP's and Doctors alike. Grrr.

April 1, 2009

United Healthcare (UHC)
Reference #1918125424

We received your letter dated March 16, 2009 and are disappointed with United Healthcare’s (UHC) determination that CPT#92507 is not a covered benefit under this medical insurance plan.

As quoted in your denial, treatment of speech, language, voice, communication is not a covered benefit. “UHC will pay benefits for speech therapy only to restore or rehabilitate any speech loss or impairment caused by an injury or illness or otherwise authorized by UHC.”

We are now requesting appeal to this decision.

As background, Thomas is a 27 month old very active toddler. He has Downs Syndrome and Hirschsprung’s disease. He also a Gtube for receiving approximately 24 ounces of milk or other thin liquids during the day.

It is imperative that we receive approval for him to receive speech and feeding therapies. These therapy sessions will be every other week for one hour each. The therapist is at Connections SLP and is trained in how to teach Thomas to drink from a cup and straw. This will be done to wean him off of his Gtube feedings. And yes, Thomas does have Down syndrome, and he will be able to speak someday thru these types of therapy sessions.

Currently, UHC is paying for Thomas’ Gtube supplies. This includes numerous feeding bags monthly, connector tubing which is replaced weekly, a continuous drip Infinity feeding pump, syringes, split gauze pads, bolus feed syringes, and the Gtubes themselves which are replaced quarterly. It is hard for our family to understand why you would decide to continue to pay thousands of dollars for Gtube supplies and deny our request for the much smaller cost of feeding/speech therapy. Please work with our family toward eliminating Thomas’ Gtube. Feeding therapies will be cost effective for both of us.

You have already denied the reimbursement of “ThickIt” a thickener that we purchase at the pharmacy to thicken Thomas’ thin liquids and keep his swallow safe. We are now paying out of pocket for something that Thomas needs to prevent aspiration. We are hoping that you will see the benefit of keeping Thomas safe from aspirating by providing feeding & speech therapy services.

You have already denied the reimbursement of “Prevacid Solutabs” for the reflux he gets from having a Gtube. Our family is confused as to why you believe a 27 month of toddler who doesn’t have a safe swallow could intake an oral capsule from the sheet you kindly forwarded to us of less expensive medications. Please work with our family and approve the feeding and speech therapy sessions so that someday Thomas can take the approved oral medications that you will reimburse.

You have already denied the reimbursement of compounded “Lansoprazole” which is for the reflux he gets from having a Gtube. Although you agreed with us on that appeal, you set the copay at $40. The pharmacy charges us $39.99 every 7-10 days that we get that prescription refilled. This has continued for approximately 130 weeks. We continue to be discouraged by the path of denials from UHC. We encourage you to work with us on approving the feeding and speech therapy sessions so Thomas can someday be weaned from the Gtube.

Please understand that we are not asking you for more than the minimum we believe our insurance company should help with medical for Thomas. Please review the denial for speech/feeding therapies to Connections. We hope that you will work with us while we work with Thomas toward total oral feedings and discontinue his Gtube.

We appreciate the time and effort you have taken to review this request. We are always available for your representatives to ask more questions.


Colin and Sandi McMillan

Tommy Adventures