The Best Offense is a Good DEFENSE

Tips to strengthen your case for coverage of power mobility devices

by Alyssa Quintero on November 1, 2008 - 10:24am

QUEST Vol. 15, No. 6

Getting insurance coverage for a power wheelchair shouldn’t be a struggle. But MedicareMedicaid or private insurance denials are not uncommon, especially when high-tech features like tilt-and-recline, seat elevators, power leg lifts and standing features are added.

But as the sports experts often say, a strong defense wins championships.

Getting what you need

Start by knowing your insurance policy inside and out. Be able to refer to specific sections or recite actual language when dealing with the insurer. Contact your carrier for clarification of policy benefits. Keep detailed records of everything, including all phone conversations and correspondence.

Next, work closely with your MDA clinic team and a knowledgeable rehab technology supplier (RTS) who specializes in power wheelchairs.

The physician, physical and occupational therapists and RTS are pivotal to ensuring that the equipment request includes all appropriate claims forms and billing codes, medical files and notes, and letters of medical necessity.

Making your case

“It’s all in the language,” says Diana Straube, an attorney with Neighborhood Legal Services and the National Assistive Technology Advocacy Project (www.nls.org) based in Albany, N.Y. “It’s important to write a letter in the beginning that will avoid the need for a denial and appeal altogether.”

Liam Russell
Liam Russell’s family battled its private insurance company for years over coverage for a power wheelchair.

The key to a successful letter of medical necessity is focusing on the medical issues behind a request. Anticipate why the insurer might try to deny the request or substitute a less-expensive option, and provide specific information about the applicant’s medical condition that justifies the request.

Some doctors don’t mind if you draft a letter for their signature. Be proactive: Stay on top of what’s being written to ensure it’s thorough.

There’s no guarantee insurers know about muscle-wasting diseases and their progression, so be sure to explain how the chair user will be affected in the future by the disease.

Adele Abramowitz, whose son Jason has Duchenne muscular dystrophy, says every piece of equipment he uses initially was denied.

“I appealed and got Jason’s doctors to write letters. If they felt that they couldn’t write the appropriate letter, I wrote the letter, and had them read and sign,” Abramowitz said.

“It’s sometimes not what you ask for but how you ask for it. If you ask for a ‘shower chair,’ you will not get it because it’s not medically necessary to take a shower. But if you ask for a ‘commode rehab chair,’ you’ll get it.”

Language should be concrete, not wishy-washy, says Straube. Clearly explain why the equipment is medically necessary and not simply a convenience item — a typical reason for a denial.

“Don’t say, ‘it would be helpful,’ and don’t give them room to read into your language,” Straube says.

But, she cautions, “try not to say too much in a letter, and only include details that are relevant to the equipment.”

More tips:

  • Request that the PT/OT also sign the doctor’s letter of medical necessity to add weight to the request.
  • Learn what criteria the insurer is using to evaluate your claim, and provide effective supplemental information.
  • “Documentation is everything, starting with the initial evaluation,” says Tara Gentile, funding manager for Permobil (wheelchair manufacturer).

Other sources of help

Power wheelchair manufacturers typically work through authorized vendors/providers, but some offer online help to consumers.

For example, Permobil’s funding department provides an online tool to help build a solid letter of medical necessity in 11 steps. (See InfoQuest.)

Pride Mobility’s product planning and reimbursement center offers its vendor/providers two services: pre-screening analysis and coding analysis. Before submitting a claim to an insurer, a Pride provider can check with the department to verify the claim meets the insurer’s coverage guidelines and that the company is being billed correctly.

Consumers can post questions on Pride’s message board; funding questions are answered by the funding department within 24 hours. (See InfoQuest.)

If you’re denied …

“Don’t take no for an answer the first three times, and request documentation to show why you don’t qualify for a program or service,” Abramowitz recommends. “Get written proof, and ask to see where it says in the program’s regulations that you don’t qualify.”

Your doctor and his/her staff may help determine why a claim was denied and write a more effective letter.

Be sure you’re informed about your appeal rights and any specific requirements, especially the number of days you have to file an appeal. Consider using certified mail to have a record of your correspondence.

And, if you threaten a lawsuit against the insurer, proceed with caution. Lawsuits are pricey and lengthy, and may not be worth it in the long run. One strategy is to copy your attorney or legal advocate on all written correspondence with the insurance company — a subtle approach that may grab its attention.

The most common reason for a denial is inadequate documentation of medical need, notes Tara Gentile, Permobil’s funding manager.

For example, Mark Airel, 43, of Liverpool, N.Y., who has ALS, was denied a power wheelchair four times before he finally received approval for a Permobil C300 with tilt and recline.

“The insurance didn’t think he needed it at the time,” says Mark’s wife, Patti. “Once the doctor wrote out all of the terms explaining Mark’s progression … that took care of it. The doctor explained that with ALS, Mark may walk one day, and may not be able to walk the next day.”

He also explained that Mark needed a power wheelchair instead of a manual one because he couldn’t use his arms and needed trunk support.

Patti says she realized that insurance companies don’t understand ALS. For example, the company said it needed scientific proof that a power wheelchair would benefit someone with ALS. So, Mark included the definition of ALS in every message he sent to the company.

“Make sure the doctor says exactly what he means, and make sure he spells it out in language that a child can understand,” urges Patti Airel.

Gentile notes that many of Permobil’s special features, such as power standing or tilt-and-recline, are typically denied up front by Medicare. However, Permobil’s funding department has won many of these cases on appeal. Gentile says denials usually occur because the documentation requirements weren’t fulfilled in the first claim.

Although it can be a huge time commitment to follow up with paperwork and forms, Diana Straube encourages consumers to file an appeal because “you can’t win an appeal you don’t do.”

A wheelchair for Liam

For Liam Russell’s family in Corvallis, Ore., providing Liam with mobility ended up being more important than battling their private insurance company. After Liam’s parents, Ben and Lynn, received multiple denial letters, they pulled together $23,000 to purchase a power chair to accommodate Liam’s type 2 spinal muscular atrophy.

Almost three years later, the family is still out the money for his SnapDragon power wheelchair, which has a seat elevator that takes him from floor to eye level, and an adjustable tilt feature, providing the 4-year-old with freedom and independence. He’s expected to outgrow the chair by age 10.

Liam’s doctor and physical therapist prescribed a power wheelchair shortly after his diagnosis in July 2005. However, when the claim was submitted to their insurance carrier, Assurant, Lynn got a phone call saying coverage was denied.

“I couldn’t have been more surprised,” Lynn says. “We began submitting appeals but to no avail. We were told that our insurance policy just didn’t cover power chairs — end of story.”

Like many families affected by neuromuscular disease, the Russells didn’t have a lot of spare time to fight the insurance company. Ultimately, Liam’s grandmother, Amy Kaplan, took up the fight for them.

The Russells’ insurance policy states: “Supplies and durable medical equipment … is limited to … one non-motorized wheelchair … and other durable medical equipment (DME) and supplies that we determine to be covered.”

Kaplan’s argument was that the policy language is vague, and because power wheelchairs fall under the definition of DME, they should be covered. Although the policy doesn’t specifically state that power wheelchairs are excluded from coverage, the insurer insisted they didn’t meet its definition of DME.

“My feelings,” says Lynn, “quickly turned from surprise to outrage.”

The Russells thought they’d done everything right. They’d followed the instructions for the appeal process, and submitted additional letters of medical necessity, but the insurer wouldn’t budge.

Kaplan took the case to the Oregon Insurance Commission. The commission investigated, the claim was denied again, and the case was dropped.

Kaplan again requested a meeting with Assurant to discuss the basis for the denials. Nearly two years after the original claim was filed, the company granted her a meeting via telephone with the grievance panel — and once again denied the claim. Kaplan was told she could get an independent evaluator to review the decision, but that Assurant was not bound to follow the evaluator’s recommendation.

Kaplan decided not to hire an attorney. “Liam had a wheelchair, and I knew they would drag this out for 10 years, and they have far greater legal resources than we have. Why should the family go through all of that?”

Instead, Kaplan decided to tackle “the bigger issue,” and contacted the TV show “Good Morning America” about the family’s struggle for wheelchair coverage. Once Assurant was contacted by GMA for interviews, it agreed to study the “feasibility of covering power mobility devices,” Kaplan says.

The GMA story aired in October 2007, and in February, Assurant’s CEO advised Kaplan that the company would cover power wheelchairs in new policies. However, just what that means remains to be seen.

“You have to be persistent,” Lynn Russell advises. “Don’t be afraid to write letters, call your insurance company again and again, contact the media. The irony of this is that people with special needs kids don’t have a lot of extra time on their hands, and I think this is exactly what insurance companies bank on.”

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