UHC Oxford denied our Occupational Therapy claims despite ADHD diagnosis and medical necessity recognized by Dr.

[Mpd7059]

United Health Care Oxford denied our claims for Occupational Therapy despite our Neurodevelopmental pediatrician diagnosing him with ADHD and recommending OT twice a week as medically necessary. UHC denied our claims saying they disagree as OT being medically necessary. They don’t get back to us. Should I hire an attorney?

[Onthemove1971]

Call them and ask Why? Then appeal.

[Onthemove1971 in reply to Onthemove1971]

If after the appeal it is still denied, write a letter requesting an OT assessment in the school district ( don't know how old your child is) then 60 days from the request you will know if the school OT can help you.

[Redpanda5]

Hi! I’m guessing this is your medical insurance provider? When we had a child in OT it was not covered by our insurance company. I could be wrong, but I think that it’s a pretty common thing to not be covered.

[MohonkHiker]

My insurance (which goes through Cigna) won’t cover my daughter’s OT either. She is receiving the OT for her ADHD and Executive Functioning issues. According to my insurance, these are mental health diagnoses and my mental health claims, which are paid by Optum, doesn’t cover OT (only the services of psychotherapists like psychiatrists, psychologists, and social workers). It’s very frustrating because the OT is really helping my daughter, but it’s very expensive paying out of pocket!!!

[ADHD_DAD]

Hi. Others have posted here in the past about United Healthcare not paying for services "out of network" or that they have deemed to not be "medically necessary." You should have been provided with a Benefit Summary booklet (or you can request one from whomever handles your insurance if this is an employee plan). The plan will include both a "claims" and an "appeals" procedure description. I have seen these before and have seen a sample one on -line. For example, the paragraph regarding a “non-network provider” sets forth the procedure to follow to seek reimbursement for out or network care. Presumably, there is a similar paragraph relating to denial for lack of "medical necessity." These plans tend to include very specific step by step instructions on how to pursue claims and appeals for denial of payment. These insurers count on people not reading these provisions and just accepting that they will not pay without challenging it. Ultimately, if you follow the steps of their claim and appeals procedure and still are not successful, you can actually sue them in small claims court. Many of these courts remain accessible completely on line (thanks covid), so you don't even have to go to the court to commence an action (and you don't need a lawyer for that; United, on the other hand, would have to hire and pay a lawyer to defend). Typically, you will reach a point where the cost for United in just paying for the OT is less than the cost of continuing to deny it. Usually, at this point, if not before, they will start to pay for the service. You can certainly hire an attorney to do this reading for you, but I would doubt the lawyer would charge less than the OT, so you'll need to decide if that's preferable to reading and following the procedure yourself or just paying for the OT out of pocket. My advice is to read the plan yourself. Good luck.