What diagnoses are and are not reimbursable by insurance?

I have heard that some mental health diagnoses are reimbursable by insurance and some are not? Does anyone know which ones are and which ones aren't? For example, I have heard that PDs are not reimbursable, but I don't know if this is true.

I know the clinician knows which diagnoses are reimbursable and so knows which to list on the insurance form. But I am curious to know too.

For example, I go to a PNP and she puts down on my insurance form, "Major Depressive Disorder, Recurrent." However, I am not depressed. But I guess this is a good, reimbursable diagnosis, perhaps? I see her for ADHD and have two prescriptions for this. If she put down ADHD on the insurance form, would she not get reimbursed? Or perhaps she is doing this for my sake--there is more of a stigma associated with ADHD perhaps, than with MDD?

When I went to see a family therapist with my daughter, he billed to my insurance, just for me. My daughter was never listed as a patient. I think this is because my insurance only reimburses for individual therapy. The diagnosis he gave was "Adjustment Disorder," which as I understand it, is just about the most mild diagnosis one can have. I like that insurance will reimburse for this.

My daughter also sees a therapist, who we pay out of pocket, but her therapist said that if we did go through insurance, she would list "Adjustment Disorder" as the diagnosis as this was the most benign.

Has anyone ever been given a mental health diagnosis that was turned down by insurance? (I am currently facing this issue with a physical health diagnosis that my insurance will not reimburse for--TMJ disorder.)

I think this varies from company to company. I finally got insurance in January, only to find out that because I've been seeing a psychiatrist for 6 years that all of my mental problems are pre-existing conditions and NOTHING related to my mental health is covered. Not therapy, med appointments or prescriptions.

I also think it has to do with what the most common treatment plans are for a given disorder; PDs, like Borderline, usually want a set "course" of therapy for X weeks, etc. and are more along the lines of a treatment for a physical disorder. The insurance companies like the known, but kind of have to put up with the "serious" too, like major depression, etc. But the lesser-known illnesses where there's no agreed-upon treatment or time-limited treatment, those are too squishy for their liking.

Here's part of the exclusions for my insurance:

and here's another good one

So isn't that just nice?? Also, I wonder how long the "period necessary" is and how it's determined? My Psych codes my paperwork as BPNOS, even though she said I was BPII....

I'm just glad that I'm not limited to 20 visits a year anymore.

Queen, that is absolute bullsh**. Seriously, if we were to say the same for "regular" medical problems, seems like most things wouldn't be treated. Let's see... diabetes doesn't "substantially improve", COPD doesn't "substantially improve", many cancers don't "substantially improve", and then there are things like arthritis, bursitis... hm, better be careful, I may be giving insurance companies ideas of other things to not cover because they don't substantially improve with treatment!

Insurance for mental health issues has trouble sort of like for dental; only people who need it are in the group so it's not really "insurance".

Insurance is for "in case" you get sick, not if you are (why often pre-existing conditions aren't covered). Chronic conditions like diabetes and COPD one doesn't go to the doctor's that often, it's mostly just meds (and if your insurance covers for meds (mine doesn't) then that costs the consumer more for that reason).

Too, if you pay X insurance dollars a month but go to the T @ $125+ a week, no way they can cover that. That's why Medicaid is so crummy, it's welfare which comes out of taxes which there's only so much of and the more people on welfare or social security and the fewer working, the less the money goes around.

I recently qualified for my states medicaid and am totally covered for therapy sessions up to 52 sessions a year, all medications and total dental coverage, my medicaid coverage also any hospital stays that I may need. my physicains and mental health professionals are covered if they are on the list inside the handbook I recieved when I was approved. when I compared that list to those we have on the list we use to refer our crisis center cleints to I found all but one psychiatrist was listed in the hand book. the one that isnt in the handbook recently went out of business due to terminal illness.

what Im trying to say is not all medicaid is crummy and and every state and insurance has their own way of doing things.

to find out what your own personal insurance, medicaid or medicare will cover call the 1- 800 number that is listed in the phone book and is also listed in the paperwork/handbook you recieved when you signed up for that insurance plan. your insurance company can tell you based on your own states guidelines and insurance policy what you are covered for and what you are covered for, what medical and mental health and dental health providers are a part of your insurance plans for you to choose from.

this information of course is just in the USA those outside the USA you will have to contact your own insurance people to get the info for your locations, what kinds of insurance is available to you that kind of thing.

My insurance doesn't work that way. Mental and physical problems are covered under Medical Insurance. All people who sign up for the plan become part of the group, whether or not they have mental or physical problems. Same with Dental Insurance. When you sign up for the dental insurance plan, you get coverage whether you need it (have dental problems) or not (require only check-ups and cleanings). I'm not sure why you think a person would sign up for dental insurance only if they needed it. Then they wouldn't be covered for their routine care or potential future problems.

QueenAccountant, thanks for posting the mental health exclusions from your plan. That's something along the lines of what I had expected, that conditions "that are not subject to favorable modification or management" are not reimbursable. That's very similar to what I am facing with my TMJ disorder. There is no agreed upon treatment that consistently works, so they won't reimburse for any expenses or treatment related to the condition. I do find this inconsistent, as others have posted, with chronic diseases and fatal ones too, such as certain cancers. But yeah, we better not squawk about this inconsistency in their logic, so coverage for fatal and incurable conditions isn't lost too.

Good post, Sunrise. I agree with everything you said. I think that often personality disorders are not covered under insurance because there is not a "favorable modification or management" system for these types of problems. A pill isn't going to help, and mental health is still treated very much under the medical model of insurance. If there is no tried and true plan of management, it simply isn't covered (like TMJ that you mentioned). That's why often our mental health providers may actually put down a different diagnosis, one they know will be covered. They are working around the insurance system.

I'm actually not sure whether my insurance covers personality disorders or not as I've never had a doctor use that diagnosis for insurance purposes. Hmm.. I'll have to look that one up. I'm curious.

This is an interesting article from a psychology group providing services:

http://www.conditt.org/index_files/paying.htm

I think it will depend on which insurance you have. I have had two different insurances and one covered my diagnosis and the other didn't so I had to switch.

Hmmm I'm certainly no expert in this area now ... but any diagnosis that is included in the DSM-IV is covered by insurance that allows for mental health coverage. ADHD is in the DSM. I would ask your doctor directly about her billing, and your concerns. She may have a simple answer for you.

I worked for a hospital. Not all diagnosis in the DSM IV are refundable.

Last year I had a limit of 30 visits for "mental health" & that included my visits to my meds provider who was out of network so I didn't file her receipts (as insurance paid a pittance) but later found out that they would have covered her over the 30 visits!! as they didn't want me to go without my meds...

But I was going for individual therapy & DBT & insurance counted both equally as visits so I had a hell of a time to not get the DBT filed w/my insurance company (had to file a complaint w/the state that oversees the mental health facility as the facility refused to agree to only file my individual therapy & let me pay out of pocket for my DBT to get "more bang for my buck").

Still dealing w/this hassle...

Hi All!

I worked in insurance land on the clinical side for over 8 years on various states and contacts.

What Queen quoted is unfortunately pretty typical. Any personality disorder as a primary diagnosis is usually not billable. Thankfully, few other disorders have this exclusion.

Sunrise- if i had to guess why your PNP does this, she is probably able to justify a longer treatment plan to the insurance company and get more session for with a mood disorder rather than ADHD.

Hope this helps!

Up until this year, my insurance covered 30 sessions a year, and my T used "adjustment disorder" as the diagnosis.

This year, my insurance pays for unlimited visits, but only for certain diagnoses. PTSD happens to be one of them, and I do have PTSD, so T is using that. he said there is more paperwork involved now, and that he needs to report on specific symptoms (intrusive thoughts, hypervigilance, etc). He said PTSD is a "good" diagnosis to use, because there is potentially a forseeable end to it, and it won't follow me around for the rest of my life.

That is interesting about the ADHD, sunny. Have you asked your PNP about it? I would be too curious to not ask

Insurance companies can include and/or exclude anything they want, subject to laws, some of which are at state levels. (Some states, such as Wisconsin, have state-mandated benefits that any policy written in that state must include).
Depending on whether the policy is fully insured, self funded, or fully funded, your employer also can decide what they want included and excluded.
Each policy is different in what and how they can include/exclude.
It is most frustrating sometimes trying to get straight answers and comprehensive information from the insurance company about some coverages.

I will say again that I am so grateful that I am in Australia. I just changed insurance funds because I got hospital cover for just $7 more per week than I was paying for simple extras (dental, physio, podiatry etc etc).

I do have a wait of 12 months for any pre-existing condition but they do cover it in a public or private hospital, or as an outpatient or private patient as many times as I need to go. There is also free community pdoc for 13 sessions. Though there isn't a huge amt of money from the govt for mental health, they do do a lot and take care of us.

I can't believe the gall of the insurers in the US I've said it before & I'll say it again, if they tried that here thet'd go broke from people dropping them. In my little world I would take them to an authority for discrimination against the mentally ill because that is what it is. They wouldn't place a limit on therapy for someone who lost a leg, and they'd supply him a new leg at no charge...Lobby groups need to get busy pushing the govt to rewrite the insurance laws at a federal minimum level for people with mental illnesses,

Rhiannon