This is a copy of a letter that was sent to our insurance company for reimbursement of in home therapy charges, it was approved by the insurance company we had at that time and was subsequently grandfathered in by the next insurance company that my husbands place of employment changed to. We have probably been one of only a handful of families that have recieved in home therapy reimbursement and it continues to this day. We use code #"97770 "Development of cognitive skills to improve attention, memory, problem solving, includes compensatory direct(one on one) patient contact by the provider, each 15 minutes " So if we paid a provider $12.00 per hour we would submit a billing sheet to the insurance company with #97770 X 4 = $12.00 etc....

August 21, 1995

Your Insurance Company Address

RE: Insurance Coverage Pre-Approval
********
dependent son of
*********
********
Plan number - *******


Dear Sirs:

I am enclosing a claim form for individual therapy for our son ********* who has a diagnosis of Autism. We are seeking reimbursement for in home intensive applied behavior therapy or behavior modification through discrete trials for our son which is currently the only therapy that has been found to recover autistic children to any degree.

********** does provide covered services for autism and this is the therapy of choice for our son. Dr. ******** has written a letter of support for this program as well as Dr. ******* a psychologist at Meyer Rehabilitation Institute. We have secured the services of ******** and ******* both of which are being trained by the Center for Autism and Related Disorders in Encino, Ca.. There is no licensure for these type of therapists and they have the only qualifications available for this field. We will have Dr. ******** and Dr. ********** oversee our curriculum and progress as well as Dr.Doreen Granpeesheh the clinical director of C.A.R.D..

Our discrete trial curriculum is based on the work of Dr. Ivor Lovaas and the “Me Book”and serves as the written plan for our son. All of the training personnel at C.A.R.D. have been trained at the UCLA Clinic for the Behavioral Treatment of Children under the supervision of Dr. Ivor Lovaas and have a minimum of two years of experience before being sent out to train families and paraprofessional personnel in the technique.

There is no service agency in ****** to provide this specialized therapy and no approved home care agency, hence paraprofessionals that we have hired and have had specially trained will be providing this service in our home forty hours a week for a period of up to two years at which time we hope ******* will be recovered sufficiently to be placed in a normal school atmosphere. The program is held in our home because this is the most efficient and effective treatment location. The program involves extended treatment hours and days so the home setting is the least confining and preferred setting, also there are no overhead costs so it is the most economical.

The curriculum that has been especially designed for ******* will cover all areas of rehabilitation for him which include programs and drills for speech therapy, occupational therapy as well as all other skills he lacks due to his neurological deficit. Behavior Modification Therapy (or BMT) is the most successful treatment in the development of speech and language skills in autistic children. BMT is not an excluded service in our Mutual of Omaha contract and as such should be reimbursable.

We have researched this therapy extensively and have found that other insurance companies have paid claims for BMT, some have done so voluntarily and others were forced by a court or threat of litigation. We prefer that this service is provided to our son voluntarily and hope that you will work with us in a spirit of good faith for the health of our precious child. We feel the cost of ******** BMT will be $50.00 per day . Assuming 300 days of treatment per year the yearly cost will be $15,000.00 for a period of up to two years.The benefits of BMT are priceless.

The BMT provided to ******* is medically necessary and has been supported by two physicians. Autism is a biological disorder alleviated by BMT. It has resulted in significant speech, language and cognitive improvements. The treatment is somewhat similar to the treatment of individuals who have suffered a brain injury or a stroke. The injured portion, or other non-injured portions of the brain are capable of compensating for the injury. Skills are learned or relearned in a slow and methodical process. The treatment of autism is not unlike this rehabilitation treatment.

Scientific studies document a 47% recovery rate and a near 100% improvement rate for children with BMT. This recovery rate far exceeds that of any other treatment.

We have hired two non-plan therapists to provide our son”s BMT who are fully qualified and who will be supervised by several licensed providers. As we are paying for all of this therapy out of our pocket we are asking for insurance reimbursement and we are asking to pre-approve this therapy for up to two years. We will gladly provide you with documentation as to his progress due to the BMT, we will provide you with any and all supervisory reports from the medical community, we will provide you with supporting scientific evidence as to why this is medically necessary. It is important to begin ******* therapy now as time is of the essence for our son and it has been documented the therapy needs to begin as soon as possible to have the best recovery outcome.

We will provide you with receipts of payments to our therapists or work with you in an acceptable form of record keeping that you request. We would like to provide you with a weekly claim form as to the number of hours ******* was provided therapy. We would like to pay these therapists $10.00-$12.00 per hour for their services. We would also like to point out that this is the most cost effective method of therapy for *******, we have checked into specialized therapy centers that treat autism on an inpatient basis and have found that they charge up to $42,000.00 per year. While we prefer not to pursue that avenue, we will if it is in ******** best interest for recovery, and if we can not come to agreement for home based therapy.

Your timely response to these issues is greatly appreciated since decisions regarding ******** therapy need to be made as quickly as possible for his benefit. Thank you for your consideration and please let us know if we can provide you with any further information.


Sincerely,