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  1. #1
    boltfam is offline Sapphire level (2000+ posts)
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    Default Insurance denied coverage for ASD therapy

    My oldest (10 yr old son) was diagnosed with high functioning ASD this summer. We are seeking out therapy for him-the psychologist that diagnosed him recommended ABA therapy and CBT therapy. We met with two places in town, and we just got a letter from our insurance company saying that our plan does not cover learning/ behavioral disorders. It says " no benefit will be paid for special education, treatment, or training for learning or behavioral disorder".

    This seems ridiculous. I can see if he didn't have a diagnose, but he has autism. Has anyone else experienced this? What premise do I have for disputing this, and/or where do I go from here?

  2. #2
    mmsmom is offline Platinum level (1000+ posts)
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    You need to go through to process to appeal it. Standard practice for many insurance companies is to first deny coverage. Your doctor or therapist office probably has someone with experience in getting insurance to cover these therapies- ask them for guidance.

  3. #3
    ArizonaGirl is offline Platinum level (1000+ posts)
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    My DS was diagnosed at 4 and at 8 we began the long process to get ABA therapy and it was initially denied.
    We are currently going through the appeal process as well.
    No advice just commiseration and
    Lindsey

    Married to DH June 2005 gave birth to Shawn December 2008 and Lilian August 2012




  4. #4
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    Default Insurance denied coverage for ASD therapy

    Pretty typical. Insurance companies are so evil. They even deny routine benefits that are clearly Spelled out, like speech. But Iíve heard it is rare for them to cover the therapies you suggest without a big old fight or recent class action lawsuit as some parents filed in our state. And when they are excluded from coverage as looks like in your case, and pretty standard, an even bigger uphill battle. Might contact your stateís insurance commissioner. Sorry.


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    Last edited by HannaAddict; 01-13-2018 at 05:29 PM.

  5. #5
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    What are you hoping to get out of services for your child? Our insurance doesn't cover ABA, but it covers speech therapy when the SLP codes the therapy for communication disorder. (His diagnosis is ASD though.) I personally find speech more helpful than ABA - it is directly provided by a professional vs the random college students we got who were trained as "ABA techs" when we paid out of pocket for ABA. Very few of the families I know of with older ASD kids still take them to ABA - they get more benefit from social skills groups and/or individual or grouped speech therapy. Our SLP works out of an ABA center though (so can consult with the BCBA if there is a need to.) My DS is 10.

  6. #6
    niccig is online now Clean Sweep forum moderator
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    Also look into your regional center. Here in CA, regional Center does early interventions for birth to 3, and provides services for older children with Autism diagnosis. Would he qualify for state insurance? Sometimes you can get services through that.



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  7. #7
    boltfam is offline Sapphire level (2000+ posts)
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    Thank you all for your responses and advice. I'll call the therapist's office on Monday and see what their experience is as far as what we should do from here.

    I totally agree about insurance companies being such a pain. Most of the times I've had to deal with them, the person I'm speaking to in inept, and what they say makes no sense. I've appealed lesser claims and lost, but hopefully the therapist's office will help.

  8. #8
    boltfam is offline Sapphire level (2000+ posts)
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    We're hoping for him to learn better social skills, so that is part of what we're looking at. I'll have to look into seeing an slp for that.

    The ABA would mainly be for self control as he often uses force with his siblings at home. We're also hoping to get a good counselor who can help him work through social nuances and how to process other people's' interactions with him.

  9. #9
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    Quote Originally Posted by boltfam View Post

    The ABA would mainly be for self control as he often uses force with his siblings at home. .
    That is hard, and having a BCBA come to our home to take data and create a behavior plan when our DS was aggressive helped immensely. We needed as a family to better understand his triggers, and how to respond so we all did the same response (we were all over the place which with kids with ASD who need consistency made things get worse, not better), and how to shape his behaviors so he had incentive to change. Changing the home environment and training us about autism was probably a bigger piece than getting direct ABA services. Basically - don't despair if you can't get him direct ABA therapy because there will still be other ways to get help, and ways you can apply the principles at home.

  10. #10
    pastrygirl is offline Diamond level (5000+ posts)
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    Yes. Ours wasnít covered, either, so I had to get supplemental insurance for my son that specifically covered ASD services.

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