T12 Para: Wheelchair denial as not medically necessary

[foton]

Hello,
It sounds unbelievable, but it is true. Aetna refused to cover cost of the wheelchair. I am T12 para and all the paperwork has been submitted to them through my neurologist from Georgetown Hospital in Washington DC. Did anyone has previous problems with Aetna? This is really ridiculous since I pay for PPO option. Any ideas how to deal with them?
Thanks

[Broknwing]

I had an Aetna HMO as my COBRA plan providor from the job I had prior to getting injured...I spoke with the people at my local DME when I was shopping for a chair(I wasn't provided one out of rehab, long story) and they advised me that Aetna's guidelines across the board were $1200 for a non-customized, non lightweight wheelchair and you can-not self-pay the difference to upgrade...They had been able to work around every other insurance co's standard guidelines when it came to people w/SCIs but not Aetna's...They advised me of places to find second-hand chairs for less money than what I'd have to pay out of pocket since my coverage was so lousy & they knew I couldn't afford to buy a new one...I don't know if Aetna has changed any in the past 4yrs but if not, that's probably what has happened to you... it REALLY SUCKS....and for that reason I"ll avoid Aetna in the future...

I learned REALLY REALLY fast that you have to scrutinize ALL the coverages in a medical plan before you ever think you might need it...

[KingofOkeefe]

I think almost all DME I got from BCBS was denied. I had to call and bitch and cry. They pay a college educated nurse to use only her right hand to use a rubber stamp on your needs.

They figure if they wait you out you will give up. It was a joke what I had to deal with. They almost seen a man go postal on the insurance.

[SoFla]

Try contacting your state's insurance commissioner. We once went that route with a property insurance problem.

[darkeyed_daisy]

I am not familiar with Aetna but if it were Medicare I could help with a Medical Necessity appeal. It really depends on what your policy says.

Unfortunately some insurances can get away with this.

[Rrrrronnn]

These stories give me impulsive daydreams of watching the CEO's of insurance companies getting their necks snapped.

Sorry foton, good luck with whatever transpires.

[Mikefxstb]

Never had Aetna...But i'm fighting with Medicare right now...I need a $30.00 repair on my chair and they refuse to pay for it cause they didnt buy the chair originally. But they'll pay for a new chair..Makes alot of sense dont it? And they wonder why healthcare costs are so high. Its no wonder they say in the future that someday there will be no money left for Medicare......

[skippy13]

Foton It could be something as simple as the way the request is worded. I would try to get an explanation of the denial in writing and ask them to be specific about which points they based their denial on. Then try to fix it by re writing the request. Then if all you can do is fight them, dont forget the ombudsman at your congressmans office, the insurance commissioner for your state and the attorney general for your state. If they are just messing with you hit them with some bad publicity too. Aetna is notorious for this kind of thing.

[SCI-Nurse]

You always have the right of appeal, and nearly always have to use it for anything but the very cheapest option. You also have the right to request (and this would require) that the appeal be reviewed by the appropriate specialist physician...in this case a physiatrist. How the medical letter of necessity is written is critical for this. If you current physician or PT does not know how to write a good one, you need to find someone who does. Quoting the recently published clinical practice guidelines on Upper Extremity Management in SCI related to types and weights of chairs would also be very important as this establishes a standard for what is medically necessary.

(KLD)

[momo3]

I have been round and round with my insurance company also. It took a year of phone calls, letters from my doc. and prescriptions to get my cushion covered as a Durable Medical. I took me a week of almost daily phone calls to get my "one chair in my lifetime" covered. Tilite has sample letters of medical necessity that you can use. Check out their website-tilite.com. Good Luck!

Kathy

No I am not a salesperson for Tilite-just happen to own one and needed the letters.

[Foolish Old]

There is a special place in hell for those who earn bonuses based on how many claims of the medically needy that they deny. The entire process is so cynical. They understand your need. They cynically refuse, ignore and delay your claim knowing you will likely accept passively, become frustrated, too frail to fight, too angry to advocate effectively... They want you to surrender or die before they need to pay. At the worst for them, they put off the expense as long as possible.

Sad! We need a new, pro consumer, health care system. We shouldn't have to get sick trying to take care of our medical needs. SCI is hard enough without having to beg & fight for every aid and treatment.

[LaMemChose]

If you appeal with proper documentation and are still denied, it's take it to the media time. Several consumer interest/healthcare reports detailing Aetna's position against your absolute medical need just might tip the scale in your favor.

[foton]

This is actually an appeal. When I have submitted first request they approved.......front and rear wheels . They refused to pay for the frame !!!! It looks like they want me to do some do-it-yourself work . This is like watching John Waters' movies. So, I did call them and after spending almost three hours on the phone I was able to talk to the lady who told me being T12 para is not enough to get a lightweight chair. My neurologist has to write a long letter with explanation why I need a chair. There was no reason to continue the discussion after she said it is not her decision but company policy. But, I was really curious who is responsible for making decisions based on submitted documents. To my surprise........a physician. How someone professional can take that kind of job?
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[foton]

Thanks for your suggestions. I think I will contact state's insurance commissioner. Unfortunately, I had nothing to do with selecting Aetna. My employer did. But, whoever is looking for insurance company beaware of Aetna. Their policies have no sense. This is a link to 0271 policy bulletin on which wheelchair decisions are being based on. Great reading for someone with insomia.
http://www.aetna.com/cpb/medical/data/200_299/0271.html

[stephen212]

Why are wheelchairs coded as Durable Medical Equipment, for which insurance benefits are typically meager, and not Prosthetic Equipment, like replacement limbs, for which insurance coverage is bountiful? It may just be hearsay, but I've been told that high-tech prosthetic legs can cost well over $10K and that many (most?) insurance plans cover it without blinking. The explanation for the disparity in coverage must be exquisitely nuanced. Can anyone break it down for us?

Foton, can you post your Aetna's policy for prostheses?