Insurance Coverage For Adaptive Items

Individuals with dup15q syndrome may need a variety of adaptive equipment, to keep them safe, to help their caregivers provide appropriate care, and to support independence.

Insurance Tips

Here are some insurance tips from Complexchild.com – Some adaptive items or other assistive technologies may be covered by Medicaid or private insurance as long as they meet a medical need. Some state agencies, charitable organizations, or private funding organizations can assist with the cost of the assessment and/or equipment. Check to see if your state or insurer has specific guidelines that must be met.

 Insurance Request Process:

Request your child’s doctor to write a script of medical necessity and include one of your own.

Submit a Letter of Medical Necessity

• Include all of your child’s diagnoses in the first paragraph,  noting the symptoms that are relevant to needing the adaptive item. 
  • Specific diagnoses that are helpful in obtaining adaptive items should be highlighted, including:
    • Muscle conditions (hypotonia)
    • Seizure disorder
    • Movement disorder
    • The inability to communicate verbally
    • Cognitive impairment or developmental disability
    • Severe behavioral disorders
    • Self-injurious behaviors
    • Balance problems (including the inability to sit up or unsteady gait)

• Include a short paragraph about why products available to the general public do not work. 
• Next, you need to prove that all the features you are requesting are medically necessary. Do not mention a specific model or brand. Simply list out the features you need medically and explain each one.  
• It can also be very helpful to explain how the adaptive item will keep your child out of the hospital by preventing medical problems.
• Now you can state that whatever item you want meets all of your child’s medical needs.

If possible, attach both a cognitive/behavioral assessment of your child (if relevant) and a physical assessment of your child performed by professionals. If you do not have these assessments, have your child’s physical therapist or other medical professional write a summary for you using a standard scale. Your physician may also summarize your child’s previous assessments in the letter.

Depending on your insurance and your provider, this step may vary somewhat. Some families may submit all the necessary paperwork directly to their insurer. Others will need to submit it through an equipment provider. You may also need to submit a prescription from your doctor and other information.

Medicaid or Medical Waiver: EPSDT Program

For those of you who have children in Medicaid or a Medicaid waiver, there are additional protections that can help you get the items you want and need. There is a federal guarantee, called the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program that requires states to cover any item or service that a physician has deemed medically necessary as part of a child’s treatment plan. Make sure your letter mentions that the adaptive item(s) is a required part of your physician’s treatment plan for your child’s specific diagnosis, and must be covered under EPSDT. Including the words “treatment plan” and “EPSDT,” as well as your child’s specific diagnosis in one sentence will alert the state that you know your rights under federal law and expect them to comply.

Expect a denial and be prepared to appeal

Insurance Appeal – How to Appeal an Insurance Denial: 9 Steps to Success – Complex Child