When your child's medical care is denied by insurance, the stakes feel even higher. This guide helps parents navigate the appeals process for pediatric denials, from therapy services to specialized treatments.
Commonly Denied Pediatric Services
- Speech therapy: Often limited to arbitrary visit caps
- Occupational therapy: Denied for developmental delays
- ABA therapy: Autism spectrum interventions frequently challenged
- Pediatric specialists: Out-of-network when no in-network specialist exists
- Mental health: Residential treatment for adolescents
- Genetic testing: Diagnostic workups for rare conditions
Special Protections for Children
Essential Health Benefits
Under the ACA, pediatric services are an Essential Health Benefit. Plans must cover:
- Pediatric dental and vision
- Age-appropriate preventive care
- Developmental screenings
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Medicaid-enrolled children under 21 have the strongest protections:
- Covers ALL medically necessary services
- Even services not in the state Medicaid plan
- Screening must be provided at regular intervals
Autism Mandates
Over 45 states require coverage of autism services, including ABA therapy. Coverage varies by state.
Appeal Tips for Parents
- Document your child's developmental milestones and delays
- Get evaluations from all treating therapists and specialists
- Request school-based assessments (IEP/504) as supporting evidence
- Know your state's therapy mandate requirements
- Contact your state's children's health advocacy organization
- For Medicaid: File a fair hearing request for EPSDT services