Medically Necessary. Is this a joke?

When you have a child with a medical condition or a disability you aren't prepared for a lot of things on your road ahead. One thing I never thought I would have to worry about is waiting for insurance to approve medical care that is clearly covered under our plan. After all, you go to the doctor to get a diagnosis and get recommendations. If the doctor prescribes a medication or service it should be common sense that it is in the best interest of the child or patient right?

Our private insurance came with a book that goes over things they cover and things they don't. Right there in the book it clearly states that they will cover $42,000 a year of ABA therapy services from a licensed agency/therapist. Sounds simple enough right? Well imagine my surprise when I go out to my mailbox and pull out a letter from our insurance company denying ABA services. Their reasoning was that they didn't get a comprehensive background check from the lead therapists that would be working with my son that the center sent FIVE times! This is private insurance we are talking about why exactly does their background check matter seeing that this is a licensed center? Why can't I get anyone to give me answers or return a call?  You take our $400 a month without batting an eye shouldn't that entitle me to a phone call.

To top it off the letter says at the end you can appeal this decision or send in the requested information upon receiving it we can then determine if these services are medically necessary. WHAT? First, our doctor prescribed these services -- they are proven to work and are recommend for children who have our diagnosis. Second, couldn't you find out if it would be qualified as a medically necessary service before you go as far to deny him for something as simple as a background check? Third, its written in black and white that it IS covered so obviously your company is aware that its a medically necessary service! Gah!

Don't even get me started on trying to get him disability insurance through the state! I applied in May its nearly November and we're still waiting. Maybe by the time he starts kindergarten he'll be approved for ABA therapy services. Sheesh!