Need Urgent Help!

[DS3]

~long story short~

I need references, books, websites, etc. to make an appeal to my insurance company to continue services for my AD/HD 5 year old who has also been diagnosed with ODD. Any links, or books, or professionals that you can suggest showing how an ABA therapist can help to improve the AD/HD and ODD conditions would be greatly appreciated. **Note, developmental delays are noted with difficult child 1 as well.**

difficult child 1 had the services and the insurance company just said 'not anymore' and didn't offer any substitution, and added that ABA therapy coverage will only be done for the kids with an Autism diagnosis. I have to send in an appeal and have all of my paperwork together for a meeting on Wednesday. So I really would appreciate anything anyone can offer!

 

[JJJ]

Is this for Tricare?

Does your son have an IEP and get some services through the school system?

Will your doctor give an Autism Spectrum Disorders (ASD) diagnosis? ODD is a tough sell since it really more of a placeholder diagnosis than a treatable one.

 

[InsaneCdn]

In our part of the world... if the psychiatrist or equivalent agrees that the services are required for this child, the psychiatrist will provide whatever diagnosis it takes to qualify for the services. They DO have some leeway in what does or doesn't fit into a particular diagnosis... expecially Autism Spectrum Disorders (ASD) or Aspergers.

 

[DS3]

Is this for Tricare?

Does your son have an IEP and get some services through the school system?

Will your doctor give an Autism Spectrum Disorders (ASD) diagnosis? ODD is a tough sell since it really more of a placeholder diagnosis than a treatable one.

Yes, its for Tri-Care, and I have a meeting with EFMP who is helping me do his appeal. They're making it an AFAP issue since they're not offering any substitutions, and just cancelling the services. (Basically, if I can get the approval again for my son, it may help the military community and their children with AD/HD get back on it too.) So I"m trying to gather as much information as I can to write the letter and have the documentation to go along with it to send in. And it wasn't so much for ODD, it was for the AD/HD that it was offered.

difficult child 1 does have an IEP, but it's only for speech therapy.

We asked his psychiatric about changing the diagnosis, but he said there's no way he falls onto the autism scale, and refused to do it. Haven't talked to the psychiatrist. Going the long way first it seems.

DS3

 

[BusynMember]

Can you get a second opinion? Anyone who says "no way" sounds as if he has closed his mind...and may not be that knowledgeable. Never hurts to get a second opinion. If you want ABA, you may have no choice.

 

[DS3]

Can you get a second opinion? Anyone who says "no way" sounds as if he has closed his mind...and may not be that knowledgeable. Never hurts to get a second opinion. If you want ABA, you may have no choice.

It takes 3 months to get into the other doctor down here. I am debating on scheduling an appointment there, but there is a chance I can get the appeal through tri-west as long as I can submit enough information and references.

 

[InsaneCdn]

Can you get both processes going - book for the second opinion anyway, it may give you a more definitive answer and therefore less issues with services etc in the future... but keep hammering away at the appeals, in case it works, as it will be a faster "immediate need" solution.

 

[DS3]

Can you get both processes going - book for the second opinion anyway, it may give you a more definitive answer and therefore less issues with services etc in the future... but keep hammering away at the appeals, in case it works, as it will be a faster "immediate need" solution.

He already has an appointment with the Neuro psychiatric for May 2013 (which I'm still fighting the insurance company on covering...), and my youngest is going to see a different Neuro psychiatric next week. If I like him, I may just see if he can take my eldest in for another evaluation. too. He doesn't seem to have too long of a wait for appointments. So we shall see.

(So yes, while I fight the insurance company on the one, I'm trying to get the other diagnosed or at least looked at while all of this is going on... Who needs sleep?!?!)

 

[OTE]

Sorry I don't know your story... for what it's worth....I did some quick research to be sure that I'm up to date.... and the only scientific research on ABA is for Pervasive Developmental Disorder (PDD). That is, it has not been scientifically shown to be helpful for anything other than Pervasive Developmental Disorder (PDD). Think of it this way... if you wanted to take a cancer drug because some doctor told you it might work for your lupus would it be wrong for insurance to refuse to pay for it? There are many, many legal cases on this issue and most, if not all, unsuccessful. The only way I can see that you might win is if you can prove that the ABA he's done to date has shown positive results. So I'd collect his testing results from before it started and the most current testing. Then find some categories that show progress and show that it's because of ABA. Simultaneously I'd ask for a list of what they find acceptable treatment for his diagnosis. All you want is a list of medical codes that they use to process claims for your sons diagnosis. There are therapies that can help ADHD, primarily psychotherapy to teach him coping skills and ways to manage focus, schoolwork, over-stimulation, frustration, etc. Even at 5 therapy might help him learn to be patient with people, recognize emotions so he can learn to control them, ...whether it's deep breathing, expressing his frustration verbally or in writing, drawing,.. any way other than ODD behavior. Also the therapist, once he/she find what works for your child can make suggestions for classroom adaptations (put in IEP) to help him use techniques he's learned in school. Another post talked about the child using "passes" when necessary to give the child time to calm down. Therapist will help child recognize when he's going to get out of control so he can use such passes both in school and at home. If there is a developmental delay therapist could do social stories. Just a lot of ways a good therapist could help him. Honestly, just conceptually this should be a lot better than ABA for a child who is not low-functioning Pervasive Developmental Disorder (PDD). If I were you I wouldn't even fight for the ABA unless it's been spectacularly successful, I'd get the child psychologist. In my experience if the child doesn't love the ABA it's not working or going to work. But that's just my experience and MHO.

 

[DS3]

Actually, if you look up the multi-model treatment for AD/HD, a combination of medication along with behavioral therapy reduces the best results. Now I just need some statistical facts to back it up along with some good resources. So I'm working on that.

Thanks for the information though. I do appreciate it.

Melissa

Sorry I don't know your story... for what it's worth....I did some quick research to be sure that I'm up to date.... and the only scientific research on ABA is for Pervasive Developmental Disorder (PDD). That is, it has not been scientifically shown to be helpful for anything other than Pervasive Developmental Disorder (PDD). Think of it this way... if you wanted to take a cancer drug because some doctor told you it might work for your lupus would it be wrong for insurance to refuse to pay for it? There are many, many legal cases on this issue and most, if not all, unsuccessful. The only way I can see that you might win is if you can prove that the ABA he's done to date has shown positive results. So I'd collect his testing results from before it started and the most current testing. Then find some categories that show progress and show that it's because of ABA. Simultaneously I'd ask for a list of what they find acceptable treatment for his diagnosis. All you want is a list of medical codes that they use to process claims for your sons diagnosis. There are therapies that can help ADHD, primarily psychotherapy to teach him coping skills and ways to manage focus, schoolwork, over-stimulation, frustration, etc. Even at 5 therapy might help him learn to be patient with people, recognize emotions so he can learn to control them, ...whether it's deep breathing, expressing his frustration verbally or in writing, drawing,.. any way other than ODD behavior. Also the therapist, once he/she find what works for your child can make suggestions for classroom adaptations (put in IEP) to help him use techniques he's learned in school. Another post talked about the child using "passes" when necessary to give the child time to calm down. Therapist will help child recognize when he's going to get out of control so he can use such passes both in school and at home. If there is a developmental delay therapist could do social stories. Just a lot of ways a good therapist could help him. Honestly, just conceptually this should be a lot better than ABA for a child who is not low-functioning Pervasive Developmental Disorder (PDD). If I were you I wouldn't even fight for the ABA unless it's been spectacularly successful, I'd get the child psychologist. In my experience if the child doesn't love the ABA it's not working or going to work. But that's just my experience and MHO.

 

[JJJ]

How did your appeal go?