Monday, March 17, 2008

Not Medically Necessary

"This is a request for a motorized wheelchair for a 3 year old child with cerebral palsy, failure to thrive, chronic lung disease, and hearing impairment. She has very low muscle tone in the neck and trunk and increased tone in her extremities. She has had 3 single trials in three different wheelchairs and proved she is successful in driving and demonstrated understanding of tilting herself and using controls. A motorized wheelchair cannot be approved as medically necessary per health plan policy guidelines, as there is no documentation that "the child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a two month trial rental period, AND as a result of the two-month trial there must be evidence that the use of the motorized wheelchair has enhanced the child's overall development including such things as cognitive abilities, directionality, spatial perception, and social skills such as independence and self-concept."

The list of expletives that come to mind after reading this are not appropriate for the blog. I can think of a whole list of "not medically necessary" things that they can shove up their collective...wait, I was trying not to use inappropriate language wasn't I?

I had heard through the equipment supplier, that the claim had been denied by our insurance company because they wanted us to do a two-month in home trial, and the lucky thing is that we actually DID do an in-home trial. This really was LUCKY because we had no idea the insurance would come back with this, and we only got the loaner chair through a twist of fate and the kindness of a few people we were working with. The claim has been resubmitted with the two-month trial information, so we'll see what happens.

Talking to the nice person from wheelchair seating, and seeing the denial in black in white from the insurance company, have proved to be two very different experiences. I guess it's just hard for me to see this beautiful child...

reduced to a number and a laundry list of impairments. Failure to thrive? That all depends on how you define THRIVE!


Sarah Furlough said...

Not medically necessary? I cannot believe that the wheelchair was denied. I'm so sorry that you have to wrangle with the incurance company, I know what a headache that can be.

I am so happy, however, that you did the trial with the chair. I will keep my fingers crossed that will sway them to approve her chair!

Korrina - Lena and Kassie's Mom said...

Failure to thrive, I guess it depends on your definition of thrive now doesn't it. I have learned that far too many times a definition make all the difference. Too bad isn't it.

I am sorry to hear that you will have to battle the insurance company. I'm sure our day will come too. Keep fighting. Glad you did the trial so you don't have to wait for that yet too.

23wktwinsmommy said...

I'm sorry you have to deal with all the ... from the insurance company.
I hope all goes well with the resubmission and Eden gets her chair soon!
She is sooo darn cute!

Kelly said...

Hang in there, Billie. They did the same thing to us when we were getting a wheelchair. Something tells me that they base denials on number of digits in front of the point. If you keep this theory in mind, then you'll be ready for whatever you decide to apply for. So, let's say the next time you apply for something, the price is $1000. That's four digits. Well, you can just bet your kahootsie they're gonna deny it for SOME reason, so just be prepared and get all your ducks in a row in advance.

You'll never be surprised or irritated if you use my theory. You'll just be laughing when you already have the documentation they require!! Just ask them for their fax number! HA!

Best of luck to you in this :D It DOES get easier with time....

winecat said...

Fricking insurance companies. Mine took 15 months to pay a hospital bill from emergency surgery in Hawaii. I "used an out of network" hospital without informing them. Well, DUH. Emergency, on vacation in Hawaii. What was I supposed to do.

Anyway I got help from Health Navigators. They deal with the insurance company for you should it come to that.

Hopefully the desk jockey will look at the trial data and Eden will have her chair but you might want to store the Health Navigators info for the future.

Dream Mom said...

Obtaining approval for equipment can be tough and sometimes an unobtainable obstacle, as first glance. But there are things you can do to change the odds in your favor.

Had you not done the trial, I would have turned the tables and requested further information on precisely what they needed, how it needed to be measured and what the criteria was. My best guess is that it's just language. If for example, you asked them for documentation on what needed to be submitted for this to get approval and let's say, they couldn't precisely document the criteria needed on how it could be measured, it would be considered "fraud." If you asked and they hemmed and hawed, you could also say that you'll file a complaint against the insurance company-that usually gets their attention.

In my state, I had an excellent contact that I used for many years to fight insurance issues. It was the State Coordinator for Insurance issues at our state capital. I contacted him different times over the years and he would give me valuable information on how to fight these claims. I still call him every now and then. I should also say that calling the office is not enough-you have to have someone extremely knowledgeable and he was the only one that I could get accurate information from-just calling the number and speaking with a rep from the office was never the same. I eventually had his direct line and he helped me a lot.

More often than not, after a call to him, he would explain what they could and could not do and then I'd simply call the insurance company and explain the situation based on my new information (I didn't divulge where I got the info.) and I would nicely tell them that I'd be happy to provide the information they would like or my next step was to file a complaint against the insurance company. They never wanted this so I was almost always able to negotiate the item.

Things are harder today because most plans are self-funded (by the employer and governed by ERISA) and not fully insured plans (governed by the state boards).

One other tool I found effective was at the Easter Seals. Many years ago they had an entire book that someone had put together on how to get insurance approvals or how to appeal denials. They allowed me to use the book to get approval for some communication devices.

That being said, getting approval for motorized wheelchairs is extremely tough so you are not alone.

Finally, now that you know how the insurance company works, be certain to use that in the future. So let's say you need additional equipment down the line, you can ask what criteria will be required so you can submit the "appropriate" documents.

Two can play hardball. The key is not to get discouraged and use all of the information you can.

Hang in there.

Angela said...

When we requested a feeding/positioning seat for Jack -- the insurance denied us because "it would only serve to enhance the caregiver's, not the patient's life." Excuse me? When is the last time that person tried to sit in an impossible position to eat dinner...the list goes on and on. On this item I went my own rout and purchased a keekaroo chair...but certainly not for a wheelchair!! Billie i am so sorry. It plain sucks!

We are having wheelchair woes ourself...and I don't expect it to get any easier any time soon.

Hang in there...and please, feel free to go into a room and scream those words into a pillow!!!!!

Jennifer said...

I am completely blown away and apalled!!! How could the wheelchair have been denied!?!? This is BS! Hang in there Billie...we'll be praying! feel free to email me if you need someone to talk to...I'm here for you!

Anonymous said...

Reading that makes me sick to my stomach. Can you get the supervisor's email in the benefits department (I'm assuming that's were the letter originated) so everyone that reads your blog could send them a friendly email? Maybe that would speed up the process. Luv Liz

Just Me said...

I know it is next to impossible, but hang in there. I'm an OTR with a great love of positioning, so I do tons of custom wheelchairs. I'm considered very successful at it, with about a 99.5% approval rate in my career.

Unfortunately insurers and Medicaid play dumb games with wheelchairs. Often there are a few key diagnoses that easily are approved (in my state for adults they are Parkinson's and Huntington's chorea), and then it gets almost random from there. I've had a denial on a 20 year old kid with quadriplegia after a very successful trial with a power chair; without it he was a 20 year old kid confined to a nursing home room. I've also had denials on patients who were so very dangerous in non-custom wheelchairs, or who had physical needs that could absolutely not be fixed with a regular chair. Last year I had someone who had tons of fluid weight from kidney failure. She was far over the weight limit for her chair, meaning it was basically unsafe for her to ever be out of bed. I had to fight 3x. Then I've had people I've evaluated thinking they didn't REALLY need the chair and it is a fast and simple approval.

It makes no sense. I think a certain percent are kicked back to discourage us from trying. I also think certain diagnoses are more likely to be ignored and for a child Eden's would probably be one of them.

The good thing is that my experience has been if whoever is doing your paperwork sticks to their guns they will get approval. I truly think part of why I do well is that I've done so many and submitted so many appeals that they don't mess with me as much anymore, because they mess with me much less than others, and much less than several years ago.

liz.mccarthy said...

Oh Lord...I good friend of mine whose son is 5 and has had a feeding tube since birth was recently given this denial for "Intensive Feeding Therapy" ....."Although eating orally is socially desirable it's not medically necessary and the child can still get make-up nutrition via tube!"

LORDY! She was LIVID!!! She fought the denial and lo-and-behold got it approved!

Don't give up the fight, My last resort always is: go to your local media/tv news station, (ours has a On Your Side segment) and see if they'd like to do a story on you and the ridiculous refusal! That will get your insurance's attention!

Anonymous said...

How frustrating! What happens if when you send them the "documentation" they require, you send along a video of Eden a) doing her belly-crawl (as much as we know this is *huge* progress for her, it is heart-rending to watch for someone who doesn't know her) and b)Eden zooming around accurately and happily in the chair. Let them try to say that she can't use it or doesn't need it! Don't give up!!!
Monique in TX

abby said...

Don't get me started on insurance companies...and don't give up, either.

Insurance companies are evil incarnate. They are soulless enterprises aimed solely at making money and couldn't care less about people. Grrrrrr. (We actually had CIGNA try to revoke some of the payments made to the NICU et al for our girls this past week, and are bracing for a fight over private speech, so this has been on my mind a lot lately).

Eden, on the other hand, is a gorgeous, thriving and fabulous girl and I am so glad that you did the trial of the power chair...she deserves the very best chair and the very best of everything. And she should consider going to law school and taking up the suit of insurance companies who deny disability claims professionally. That'll show 'em!

Katy said...

Mine is twenty pounds at nine months and we got a failure to thrive diagnosis too. People are always commenting on his chunky thighs, so I think it's pretty ridiculous. Too tired to eat isn't the same as failure to thrive.

Anyway, insurance companies are the devil and from the looks of all these comments, you're not the only one. Ours denies thickener, which prevents him from getting pneumonia, because they call it an additive. Even though we've had the barium swallow and everything. I'm hoping we'll pass our next swallow and then I won't have to pay $75/month to keep my kid out of the hospital.

Seriously, they are idiots and Eden is an amazing little miracle. This stuff sucks, but I guess it's just part of the "game."

Anonymous said...

I am so sorry you need to go through this. I really understand as we have been going through very similar things with our insurance company. One company wanted electric shock done to Sean to see if his muscles worked or not. He does walk, but we need something for long distances and when he doesn't feel well, which is more often than not.
If they deny you again, turn them in to the State insurance board for your state. We have had to do that to get Sean's gtube put in and to get his formula as well as therapies.
Today they denied him seeing a Doctor we have been waiting 2 years to see! A Doctor we need to see so the other Doctors can move forward with treatment. This is his new main primary care Doctor. We are shooting for May 20th for another stab at it. This is the 5th time we have had to reschedule this appt because of the insurance. If we could afford the $1,000 price tag for this Doctor, we would be there the moment his doors opened.

Good luck!


Mete said...

Oh, GRRR, you know I feel your pain with the whole situation. So terrible. Any fool can see that this chair would benefit her in thousands of ways. (And sadly, the failure to thrive thing may actually work FOR you - sometimes, the more diagnoses you can build up, the more "need" they see.) It's hard, but keep fighting. It's a battle of the wills and they want you to give up. We've given up more times than not, simply because we didn't feel like fighting anymore.

My favorite denial will always remain Ethan's ambulance ride home from the hospital (almost a 2 hour ride) six days after surgery, in a full body cast which left him completely horizontal. For two days they battled the hospital with that ridiculous catch phrase "NOT MEDICALLY NECESSARY", choosing instead to pay for another night in the hospital. The hospital AND a social worker from the insurance company itself were stunned by that one. They never did pay - we got a grant from the hospital for that ride, and we had to buy a special harness (out-of-pocket) to transfer him, laying across the back seat of my car, to each of his follow-ups.

We've got another surgery later this year, but a new insurance. I can hardly wait to see how this one goes.

Jacolyn said...

Oh my gosh!!! How frustrating!! I'm about to begin the wheelchair battle with insurance. I dread it!!!

Anonymous said...

Are they out of their *expletive* minds? How could the wheelchair *not* be medically necessary for Eden? I know there is no low to which an insurance company will not sink to avoid paying for something, but egads. It's like 'no, we won't pay for the surgery to re-attach your severed limb until you have proved through a two-month trial that the limb is actually necessary for your day-to-day functioning.' Gah.

CG said...

The girls are so beautiful and their smiles just captivate. That is great you already have the 2 month trial under your belt.

Take Care

nancy said...

Oh different ends of the spectrum but we couldn't get anyone to order us his walker. It was like pulling teeth to get such a small piece of equipment that we were so frustrated. It is so devastating as a parent because we crave that independance that we know they can have if they are given that chance... SUCKS... here is to that power wheelchair and the CEO of the insurance company dealing with a child / grandchild with special needs as bad karma.

Billie said...

I agree that nurturing a child or grandchild with special needs might give that CEO a new frame of mind. It might open his/her eyes to the struggles that we face, and might grace them with a little more compassion. I have to seriously question "bad karma" though. I certainly don't see my children as "bad karma" and I hope that no one else does either!

Patyrish said...

What a bunch of jerks. We went through that when we tried to get Makily's special needs stroller at 18 months. Now we are in the process of getting a bed and it INFURIATES me that I know they will come up with some sort of LAME reason why not to pay for it.

It's terribly depressing that we are FORCED to reduce our kids to some horrible words on a piece of paper to get them what they need.

I pray they come back with an approval...hang in there.

Anonymous said...

As you know my husband works in the health care field and his chief complaint is how much time he & his staff spend sending multiple request to insurance companies trying to get medication/equipment he deems necessary approved. I don't know if universal coverage will be better but it sure can't be any worse!!

Take care Melissa K