My 3.5 has Apraxia of speech, and global dyspraxia. This is a neurological condition that by itself does not affect cognitive ability but impairs the ability for the brain to plan muscle movements. there are some known causes, stroke, cerebral palsy, other brain injury, gene deletion and sometimes the cause can never be found.
She is currently getting therapy 5 days a week through school and 4 days a week in private therapy after school. (Speech, OT, PT) our limit is 90 visits per year combined. For this specific thing therapy is better given in short sessions several times a week. For reference her brother who is 1.5yrs younger than her has now surpassed her in all areas.
I was wondering if anyone could tell me based on my plan if getting a specific diagnosis (for example if we get an MRI that shows she has cerebral palsy) does that give more visits or is 90 the absolute limit no matter what. If you can’t tell based on the below what questions can I call and ask to get an answer? I have tried calling in prior years to get answers to what is covered for other things and get told some version of they can’t tell me what’s covered until they see how it’s billed.
Bonus question: if she gets PT/OT/speech all on one day is that billed as 1 visit of 90?
What the plan states under “habilitation”:
PT, OT, ST covered only for developmental delays; 90 visits/cal yr for medical services; multiple visits in a day may be counted as one visit; physical, occupational and speech therapies combined; in- and out-of-network combined; preauthorization required
What the rehab company sent me:
The following exclusions were noted on this plan as well: The plan will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, sickness, stroke, cancer, autism spectrum disorders or a congenital anomaly. Habilitation for physical therapy, occupational therapy and speech therapy is covered, but only for developmental delays, and is included in the 90 visit limit for Rehabilitation.
submitted by /u/Few-Investigator8145
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My 3.5 has Apraxia of speech, and global dyspraxia. This is a neurological condition that by itself does not affect cognitive ability but impairs the ability for the brain to plan muscle movements. there are some known causes, stroke, cerebral palsy, other brain injury, gene deletion and sometimes the cause can never be found. She is currently getting therapy 5 days a week through school and 4 days a week in private therapy after school. (Speech, OT, PT) our limit is 90 visits per year combined. For this specific thing therapy is better given in short sessions several times a week. For reference her brother who is 1.5yrs younger than her has now surpassed her in all areas. I was wondering if anyone could tell me based on my plan if getting a specific diagnosis (for example if we get an MRI that shows she has cerebral palsy) does that give more visits or is 90 the absolute limit no matter what. If you can’t tell based on the below what questions can I call and ask to get an answer? I have tried calling in prior years to get answers to what is covered for other things and get told some version of they can’t tell me what’s covered until they see how it’s billed. Bonus question: if she gets PT/OT/speech all on one day is that billed as 1 visit of 90? What the plan states under “habilitation”: PT, OT, ST covered only for developmental delays; 90 visits/cal yr for medical services; multiple visits in a day may be counted as one visit; physical, occupational and speech therapies combined; in- and out-of-network combined; preauthorization required What the rehab company sent me: The following exclusions were noted on this plan as well: The plan will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, sickness, stroke, cancer, autism spectrum disorders or a congenital anomaly. Habilitation for physical therapy, occupational therapy and speech therapy is covered, but only for developmental delays, and is included in the 90 visit limit for Rehabilitation.
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