Evan does not deserve a form letter insurance reduction in therapy hours.
It is said that “if you’ve seen one child with autism, you have seen one child with autism.” You know that, I know that but apparently a very large insurance carrier doesn’t believe that is the case. We are in the midst of an appeal process to try and reinstate the therapy hours that Evan needs. His hours were cut to 15 from 40 since he is “school age”. I guess that individual decisions are not needed anymore when determining what is appropriate since we can now use an age based criteria. Evan is 7 but is not ready for mainstream school. His primary doctors have also stated that the ABA is a medical necessity for Evan to continue on his path.
It would make sense that the insurance carrier would approve the recommendation of the observing physicians but instead we received a form letter, which others have received as well. The letter states that the hours would be decreased since he “has not made the amount of progress that would be expected”. So logic would dictate that a less one-on-one classroom environment would be even better. At least that is the logic of the insurance carrier.
This issue is not just an autism issue. One part of the denial states, “He may have achieved a plateau where his skill level and behaviors may not significantly improve”. Insurance logic then dictates less therapy should be used. I am 58 years old so what if I get ill and need services. Would I have “achieved a plateau” as well so treatment would be eliminated? I am very glad they didn’t feel my wife had plateaued when she had thyroid cancer so she was able to get the medically necessary treatment.
Any difference between the medically necessary treatment Evan needs and Mindy’s scenario. I don’t think so!
I know many other families that are going through the same issue and I know I can speak for all of us—
I will not give up. I will not go away! Evan’s life is far too important to a lot of people to justify this “form letter” treatment. We are just beginning to fight but will not stop until changes are made for all of us! Keep us in your thoughts and prayers— we may need them!
Awareness is the key! (Are you listening large insurance carrier????)