I have found myself covering this information so often that I

decided to make it available for others:

When talking with your insurance carrier:

You will need to find out if your insurance company

“carves out” mental health to a sub-contractor . If so, you
will probably need to contact the subcontractor, often a
“behavioral health company.”

Ask if the following are covered by your insurance:

 Psychiatric eval as well as consultation for second opinion

if you will be receiving medication management or other
psychiatric services at another provider but
neurofeedback or psychiatric consultation with me.

 Psychotherapy with a psychiatrist

 Med management with a psychiatrist

 Biofeedback and/or neurofeedback with the psychiatrist or

a tech
(biofeedback can include hand-warming, heart-rate
variability biofeedback and
neurofeedback…..make sure you ask carefully. Some
insurance companies will pay for neurofeedback, but want it
coded as psychotherapy. Others have a flat rate they pay for
any biofeedback. Some do not cover any biofeedback in any
form.

Ask how your in-network coverage differs from out of

network.

From the beginning, ask if it is possible to be covered for

your treatment with the out-of-network psychiatrist AS IF
SHE IS IN NETWORK (This is sometimes referred to as a
“special exception” or “special accommodation”, or “ad hoc
agreement”). What this usually involves is your request, and
some lack of available of in network providers suitable for
you. If they agree, then they will contact the provider and
attempt to work out a special case agreement with the
provider, negotiate a fee, and make the authorizations
necessary.
Depending on your situation, you may want to find out if
your company covers group therapy and marital or family
therapy

Also find out the following:

 Your deductible, and the dates when they start a new

deductible period

 Your yearly or lifetime maximum dollar benefit

 Are you limited to the number of sessions they cover per

year

 Your copay.

 Ask them if visits have to be pre-authorized, and to pre-

authorize your visits with me

Ask how much they pay….whether your copay stays the

same or increases over time. Here be shrewd and
persistent. Some insurances refuse to tell you the dollar
amount they pay until they know what the provider charges.
Ask if they have a “limiting charge”, (on which they pay a
percentage –and what IS that percentage….then you pay the
remaining percentage as well as the difference between the
limiting charge and the charge the provider charges.)
Alternatively they may pay a percentage of the actual
charge. That actual charge may be the insurance allowed
amount for in network docs, or the “agreed upon fee” if they
do an ad hoc agreement.

If they insist on knowing what the provider charges, give

them an estimate, such as 320 for an initial visit and 250 for
follow up visits involving psychotherapy. (You may need to
divide the code for follow-up visits to 125 for the med mgmt.
code and 125 for the psychotherapy code.).

If you are interested pursuing insurance coverage for the

neurofeedback/biofeedback, ask about those charges and
codes too, as follows, keeping in mind that insurance may
not distinguish between biofeedback and neurofeedback the
code is same either way:
Neurofeedback with Dr. Pesaniello is 250 for eeg
neurofeedback.
(If it is pirHEG training or HRV biofeedback or hand
temperature training, Dr. P can do this for $125 in half a
session, and it is not coded as neurofeedback, but as
relaxation training along with/as part of psychotherapy with
aim of improved self regulation. The distinction has to do
with the kind of devices used and the process. In this case,
you do not need to ask about the coverage for biofeedback.
Only ask about biofeedback/ Neurofeedback for eeg
neurofeedback).
Neurofeedback with a tech supervised by Dr. Pesaniello: 75
and the CPT code is 90901. Ask if there are limited
conditions in which this is covered, if so, what are they. If
they won’t tell you ask if it is covered for:
 migraines (G43.909),
 traumatic brain injury (F07.81),
 ADD/attention disorders (F90.0), and
 mood (F31.31for bipolar and F33.0 for depression).
If they insist on you providing the diagnosis code, that is the
number in parentheses. It is important to know if they cover
any one of these, since many patients have more than one
diagnosis, you may qualify under one of them.

They will also ask for the “CPT code” or “procedure code”.
In that case, be armed with the following codes:

All individual visits for meds and therapy include the med
mgmt. code below, plus a psychotherapy code from the next
set. Two codes each time:
the med management codes : 99212, 99213,99214,
individual visits for psychotherapy:
90832, 90833, 90836,90838 this depends on length. I
typically use the 90636, rarely 90833 for short sessions
initial psychiatric eval:
99204, 99205, or 90872
90853 for group therapy
90847 for family therapy

Clarify the differences in your out of pocket expense if

you see someone in network vs out of network. If the
difference is significant, and you would like to see an out of
network physician, you may have to be insistent about
wanting a single case agreement:
How to do this? Say that you live in a psychiatric
underserved area for starters, as that provides more leeway
to those approving coverage. State what you want and
expect them to be able to provide to you as an insured
member. (A highly qualified and available psychiatrist and
the option to not have “split treatment” at a public clinic
(what most of the other options here are). IF you work or
are planning to work eventually in a clinic, state that for
confidentiality reasons you need to not have to interface
with people at public/high volume clinics for reasons of
confidentiality….Use everything you can think of that
indicates need for the accommodation. For example, tell
them you want to see a physician, and your preferences for
male or female, if you feel that is necessary (tell them you
have your reason). Tell them you want to see someone who
can see you weekly at least initially, or who can address the
medical issues impinging on mental health concurrently and
provide ongoing collaboration with your psysicians (for pain
or other stress-related medical conditions), that you want
someone who is able to provide weekly psychotherapy, has
openings, and is in a reasonable driving distance. Tell them
you do not want split treatment, if you want me to do both
meds and therapy. (“Split tx” is when meds are with one
person, therapy with another). If true, challenge them to not
insist you engaged in care that may be compromised from
the beginning by forcing you into a high volume, split
treatment clinic.

If they give you a number of in network providers who

they say can offer these things, check it out. Often they will
say they have in-network psychiatrists, but when you call,
you learn you will not see the psychiatrist except for the
initial eval, (if that), and that the psychiatrist will not see you
weekly for your therapy or even your med follow-up …. You
may soon be seen only every three months by the
psychiatrist in these clinics, while your therapy is relegated
to someone else, often someone with less training in
psychotherapy. Most in network psychiatrists are at high
volume clinics and spend minimal time with patients, and
often have high turnover…may be gone before the next med
check. Clinic docs usually won’t do med eval and
management for patients in therapy elsewhere. So they are
not available to you unless you change your therapist to a
clinic therapist. (This saves money for the insurance but
may not be best for you.)

Usually to get the single case agreement, you will have to

call back the insurance company and tell them none of the
providers are available/acceptable. So you want them to
authorize you to see the psychiatrist you have found, and to
authorize it as a special exception, as if she is in network.
(This option may give you a copay-only or less out of pocket
expense You want initial eval and follow up sessions
authorized as an ad hoc or special case agreement.

Some insurance companies offer this option, especially in

psychiatric shortage areas like the Eastern Shore.
Emphasize this.