Wiki Requesting a Policy Exception

[jlbaker10]

Has anyone successfully gotten a policy exception from an insurance company, for additional PT/OT/SLP visits? This would not be an appeal.

It is a Premera Plan in Washington state. The policy very clearly has a 14 visit combined cap and between the 3 disciplines, we've hit the cap already. I realize there is no reason to appeal the future denied claims, because the denial is valid. There is nothing to argue.

For this patient, a child with Down Syndrome, 14 visits isn't nearly enough to make any progress.

Does anyone have any tips for how I can make this happen? I know policy exceptions are generally for Drugs and out of network services.

 

[MrLittlefoot]

You probably can't. First, if this is self funded insurance that is organized in a healthcare trust, the payer would be violating federal law to provide an exception to policy. So...they just aren't going to do it. And even if they're not, since the denial is valid, there really isn't an incentive to the payer to make a payment when they don't have to. In my experience, even when a payer gives a "policy exception" they actually haven't. They just are drawing on a policy that allows an exception to be made to another policy, if the patient meets criteria x,y,z.