February 1, 2008

QUESTION: I have 9 year old son, who was diagnosed with convergence problem by an Optometrist in our area. I tried to find out if this treatment would be covered under my health or vision insurance.  When I talked with my insurance company they asked me for diagnosis code and treatment code for him.  When I gave them this information they told me that it is not covered under my insurance.  Is there some thing I can do to fight this out with my insurance company?

ANSWER: The only loop hole I ever discovered is that in some cases, some insurance companies will cover the "specific" codes and deny the codes that tend to be more general.  An example would be billing "the flu" (which is usually denied) versus a more specific diagnosis of strep throat (which usually gets covered).  You may want to ask your doctor to consider if your child would qualify for a different -- and more specific -- ICD-9 code given the diagnosis.  I am in no way suggesting the doctor manipulate the diagnosis for purposes of insurance billing; rather, sometimes there are codes that are very specific to a diagnosis (as my example above) that will help your case.  If you are willing to "play the numbers game" with the insurance company, you may discover the codes they are willing to accept.