Insurance Coverage For SPD

by Polly
(Reed City, MI )

I want my daughter referred for a sensory processing disorder evaluation. My insurance will not cover it if the referral is for that specifically.




What terminology can be used that will satisfy the insurance company? The OT department suggested "hypertonia" or "coordination disorder" but neither fits my daughter's issues.






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Aug 15, 2018
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by: Anonymous

This is a common problem! How I wish it wasn't... so many families unable to be helped due to insurance issues. We are indeed working on changing that.

For more about where we are in this process and why, read the November 2006 edition of my free monthly newsletter, The SPD Companion Recognizing SPD As A Medical Diagnosis.

You were definitely on the right track looking for other codes the OT can use to get insurance reimbursement. Given that your daughter does not have the issues the therapist recommended for codes, you may find this list of acceptable diagnostic & reimbursable codes more helpful...

Commonly Used Diagnostic Codes For SPD Evaluation And Treatment

Let us know if this helps. Is there something on this list she can fit under? Can the OT use any of these? Give her a call using this list, and call the insurance company to see if they will accept any of them. You may need a script from your pediatrician that says the particular diagnosis based on the particular code the OT will be using. I do hope they can do this for you!!

Any other therapists have suggestions for codes you've used successfully with insurance companies? Please let us know! This is a hurdle we so desperately need overcome.
Nov 27, 2007
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by: Anonymous

I am new to this website and am learning so much I wish I had learned long ago. My issues aside, I wanted to put my two cents worth regarding insurance coverage.

I work in the medical claims department of a large insurance company. I know that many insurance's do not cover developmental delay diagnosis and the procedure code for self care can also be denied as educational in nature.

Just my two cents--I have seen a diag of 315.4 which is more of a mental nature diagnosis which may work too. I think once insurance carriers are made more aware of this disorder and can consider it a neurological rather than learning disability things will go smoother.

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