Equipment Series – Part 3: Making the best arguments for insurance coverage

Posted Thursday August 30, 2012 by Melissa

Ormesa Bug

Be sure to first read Parts 1 and 2 of this series:

Equipment Series – Part 1: Before, during, and after the equipment evaluation

Equipment Series – Part 2: Evaluating and comparing special needs strollers and wheelchairs

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For most of us, the cost of a medical stroller or wheelchair is too high to purchase on our own. Luckily for most, insurance, either private or state-sponsored, covers most of that cost.

At the time we first needed a chair for Case, we had Blue Cross Blue Shield of Tennessee as primary and TennCare (Medicaid) as secondary insurance for him. However, the BCBS plan had a durable medical equipment cap of $5,000 annually. Since Case’s ankle foot orthotics (AFOs) generally cost several thousand dollars to purchase and adjust, we knew we might cross that cap in looking at a chair. In addition, since we also needed a feeding option at the same time, this was extremely likely.

So here is where my lawyer brain takes over and reminds me that the best defense is a good offense. I had heard enough stories from other families of wheelchairs being denied, being limited to specific types of chairs, and being challenged for so long that the chair doesn’t fit by the end of the appeals.

What I needed to know is how do the insurers decide whether to cover a chair (and/or feeding or activity chair) in the first place? How do they decide whether to cover a specific chair? What about all the accessories like a tray, canopy, cushions?

I started by doing a Google search using the terms “[my insurer]”, “wheelchair”, “approval”, “criteria”. One can scan the results (or bread crumbs, as I like to all them) to find the path to what you’re looking for. Set aside an hour or two because, depending on your insurer, it may take longer than you think.

For us, I was finally able to see that BCBS of Tennessee seemed to rely on certain criteria originally set forth by Aetna. Medicaid was not as easy to find.

So once I found the criteria, I took them one by one, and now having listed (from Part 1 of this series) my child’s needs and uses for the chair, I analyzed how he met each criteria.

Here is an example of our applicable criteria and a little of the thought process for Case. This is not perfect, but it helps you inform and explain more in what you are prepared to provide to the seating evaluator. By analyzing the criteria, it often helps you think about and consider additional needs your child has or ways in which you would need t use the stroller/chair. Because we get so used to our children and our life, it is often difficult to step back and consider how things might be different/easier were we to have certain equipment.

I’m not saying simply by finding and using this criteria in your thoughts that things will necessarily be easier, but like I said, it may get you what your child needs in the end. Being prepared for a fight always helps rather than being blindsided.

Here are the challenges we faced in getting Case’s chair finally approved:

  1. Case’s primary insurance (BCBS) approved the chair.
  2. Case’s secondary insurance (Medicaid) totally denied it.
  3. We met with the DME company and the evaluator again with more explanations, we paper appealed the denial and won.
  4. Medicaid denied the basket and the canopy (for a specialized chair like this, these totaled around $500).
  5. We paper appealed the denial of the basket and canopy. Here is the information we used for the appeal.
  6. We lost the paper appeal.
  7. We appealed to an administrative hearing.
  8. I showed up at the hearing and Medicaid had called in, approving the basket and canopy.

Hopefully this series has been helpful to you. I would love to see posted some success stories in finding and getting approved the equipment that your child needs!

 
Copyright © 2012, Melissa Hogan. All rights reserved.

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