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    Just got turned down for new powerchair

    It's going to be a fight. They're claiming I don't meet the needs for it under their rules. MediCal paid for a Quickie S626 with tilt-in-space, five years later they paid for my Invacare TDX-SP with the same set up but the insurance changed and now it's MediCal/SF Health Plan and suddenly I no longer meet the requirements. Sigh. I wonder how long this fight is going to take and if I can handle it. I also wonder if there is some kind of advocate I can reach out to. Does anybody know about that?

    #2
    Originally posted by grommet View Post
    It's going to be a fight. They're claiming I don't meet the needs for it under their rules. MediCal paid for a Quickie S626 with tilt-in-space, five years later they paid for my Invacare TDX-SP with the same set up but the insurance changed and now it's MediCal/SF Health Plan and suddenly I no longer meet the requirements. Sigh. I wonder how long this fight is going to take and if I can handle it. I also wonder if there is some kind of advocate I can reach out to. Does anybody know about that?
    Why do you need a power chair?, you look like a para to me, at least in your avatar.
    "Life is about how you
    respond to not only the
    challenges you're dealt but
    the challenges you seek...If
    you have no goals, no
    mountains to climb, your
    soul dies".~Liz Fordred

    Comment


      #3
      What have you done so far? Prescription from doctor with letter of medical necessity for power chair? Evaluation/specification of chair from a physical or occupational therapist? Other?

      All the best,
      GJ

      Comment


        #4
        Hello Grommet, Medicare would not payfor a sm. scooter for me. i am considered a para. even though i walk with a walker and have TM. i have a wheelchair but i cant wheelmyself at fleamarkets and outside craftshows. i had my outer rim taken off my wheelchair to get in my bathroom and kitchen. my spine dr. said its because i have use of my arms. from what i was told not by that dr. but acouple of friends i could order a wheel chair. but the scooter was only 700dollars. i know a good wheelchair would cost them more . i didnt fight it

        Comment


          #5
          Grommet, is that a Medicare HMO? Are you not now on Medicare since you have been injuried for so long? Normally you would be on Medicare as your primary and Medi-Cal as your secondary at this point.

          Medicare has signficantly tightened up the rules on power chairs in the last few years, and many other insurance companies use the Medicare standards. They will approve a power chair ONLY if you cannot get around inside your home with a manual chair. Community mobility is completely inconsequential for them, so if you are saying you need a power chair to go to the store, school, or work, or just to get around in your neighborhood or town, and can still get around in your house with a manual chair at all, you are going to get turned down.

          In addition, you must have a power chair prescribed for you by a therapist who is certified by RESNA. If you try to just go through a DME who is not RESNA certified, or just with a prescription from your provider, you will be out of luck.

          You are entitled to appeal, but the chances of you winning under the conditions above are slim to none.

          (KLD)
          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

          Comment


            #6
            Now I see why my physiatrist was pushing me to go for a new powerchair first. Guess carpetting does have its uses. Previously Between the FEP/Medicare and Tricare I got a new power and manual as needed. I think my last manual, currently falling apart, was paid for by Medicare because of the width of the halls at the Capitol and Government offices in Annapolis.

            I was going to ask if anyone has links to the Medicare areas for chairs and PT for 2013? I understand PT is being cut again and even the work around at teaching hospitals attached to the rehab outpatient area is going.
            Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow."

            Disclaimer: Answers, suggestions, and/or comments do not constitute medical advice expressed or implied and are based solely on my experiences as a SCI patient. Please consult your attending physician for medical advise and treatment. In the event of a medical emergency please call 911.

            Comment


              #7
              I have a medicare replacement plan. And hey gave me an advocate to advocate for my needs. If you have a medicare replacement plan i would ask for an advocate. I hope this helps.

              Comment


                #8
                Originally posted by Sue Pendleton View Post

                I was going to ask if anyone has links to the Medicare areas for chairs and PT for 2013? I understand PT is being cut again and even the work around at teaching hospitals attached to the rehab outpatient area is going.

                This is an important question....

                Starting this fall, outpatient PT/OT at a hospital based facility will start counting towards the yearly capped Medicare max allowed. Therapists at hospital based facilities will STILL be able to apply for extensions/exemption of this cap while you are doing therapy at hospital based facilities, but this of course is a bit unwieldy. However, I had not realized that this exemption expires in December, unless it is extended by the government. I think the exemption is linked to the same threatened 27.4% decrease in Medicare reimbursement to doctors that happens every year.

                http://www.aota.org/News/AdvocacyNew...-for-2012.aspx

                Comment


                  #9
                  Originally posted by SCI-Nurse View Post
                  Grommet, is that a Medicare HMO? Are you not now on Medicare since you have been injuried for so long? Normally you would be on Medicare as your primary and Medi-Cal as your secondary at this point.

                  Medicare has signficantly tightened up the rules on power chairs in the last few years, and many other insurance companies use the Medicare standards. They will approve a power chair ONLY if you cannot get around inside your home with a manual chair. Community mobility is completely inconsequential for them, so if you are saying you need a power chair to go to the store, school, or work, or just to get around in your neighborhood or town, and can still get around in your house with a manual chair at all, you are going to get turned down.

                  In addition, you must have a power chair prescribed for you by a therapist who is certified by RESNA. If you try to just go through a DME who is not RESNA certified, or just with a prescription from your provider, you will be out of luck.

                  You are entitled to appeal, but the chances of you winning under the conditions above are slim to none.

                  (KLD)
                  So you are saying wreck your shoulders then be put in a nursing home......sounds just like obama care....that will save alot of money in the long run huh?....my as well give us a shot and let us go out in piece.

                  Art
                  Art

                  Comment


                    #10
                    Originally posted by Art454 View Post
                    So you are saying wreck your shoulders then be put in a nursing home......sounds just like obama care....that will save alot of money in the long run huh?....my as well give us a shot and let us go out in piece.

                    Art

                    This has nothing to do with ObamaCare. This was the Medicare requirement before Obama was in office. So I guess it is "BushCare".....

                    Comment


                      #11
                      Just back online after a couple of days, sorry for the delay.

                      Thanks for all the great information. I didn't know about 'community mobility', that explains a lot. I don't have an SCI. Was started with powerchairs 17 years ago because of joint/muscle pain. When my current powerchair broke down two years ago I bought myself a manual - Tilite TR. I love the independence and freedom of using a manual but my body hasn't changed and my GP has been against me using a manual chair the whole time. My current prescription is from her and she's great. The system does seem to be coming down harder. I am confused on this denial because I am asking for the exact same chair they bought me 5 years ago. I was qualified then but not now, how does that make sense. After reading the replies I see how it could make sense if they are being more strict.

                      I have seen my powerchair on Ebay for less than $2,000. That was in my mind as a second option if I got turned down. It will take a long time to come up with that money but it is an option. I also have 90 days to appeal this decision and I am deciding on how I want to do that. Ironically, as my pain grows I am living with it better. I've learned from CC folks about living with pain. I always find a way and I will this time too. I've met people who are in total crisis, I am not.

                      I was born with brain damage. The memory and concentration troubles have been hard but there are strategies including asking for help and my friends are terrific with that. The physical has been trickier. Brain isn't sure what's going on where and I get weird sensations including burning nerve pain but I am very lucky since it's something that comes and goes. I read about living with pain that never abates and well, I'd toughen up and see what I could do if that happened but I am in awe of those who live with that kind of pain. A few months back I had a bad episode with no break and thought I would go mad.

                      The amazing reduction in pain when using a powerchair is really something. I want one around even though my primary is a manual now so that I can share the load between them and in case something happens and I can't use my hand or hands on day or for a week. I had that happen a couple of years ago and I could hardly get around the apartment. Scared me pretty bad. If anyone has a right motor for a TDX-SP please let me know, that's what's broken now. If not, Ebay sounds like the way to go.

                      Thanks again for the info, it helps me make sense of this recent turn down.

                      Comment


                        #12
                        HLH, My physical therapist just started back in June to let her Medicare primary patients know that the HOPD will disappear on October 1st. It appears the date has been changed by someone at CMIS. I got my $1880 of Part B while at the nursing center to up my endurance and deal with a compressed nerve that knocked out my wrist extention on the left. It seems I started over when I began seeing a PT to measure me for a new powerchair, we'll get everything needing fixed on the manual done on our own if necessary, and work on stabilizing scoliosis that is probably age related as much as SCI related. The HOPD and the SNF are already using the equivalent of a manual extension to guide people into a tunnel that will hopefully see light on January 1, 2013 for patients who continue to need care.

                        I will be calling our secondary BC/BS because it is based on my husband's federal service and is not a Medigap policy to make sure we don't lose benefits going forward.

                        Sue

                        Originally posted by hlh View Post
                        This is an important question....

                        Starting this fall, outpatient PT/OT at a hospital based facility will start counting towards the yearly capped Medicare max allowed. Therapists at hospital based facilities will STILL be able to apply for extensions/exemption of this cap while you are doing therapy at hospital based facilities, but this of course is a bit unwieldy. However, I had not realized that this exemption expires in December, unless it is extended by the government. I think the exemption is linked to the same threatened 27.4% decrease in Medicare reimbursement to doctors that happens every year.

                        http://www.aota.org/News/AdvocacyNew...-for-2012.aspx
                        Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow."

                        Disclaimer: Answers, suggestions, and/or comments do not constitute medical advice expressed or implied and are based solely on my experiences as a SCI patient. Please consult your attending physician for medical advise and treatment. In the event of a medical emergency please call 911.

                        Comment


                          #13
                          Sorry for your problems getting a chair. That's why I only use Medicare part A. Fortunatly I'm covered on my wife's insurance from work. They approved a power chair in no time, but I don't meet criteria for skilled nursing inpatient care after bilateral rotator cuff surgeries since I won't be in the hospital for 3 days. Medicare's rule I'm told. Lovely system we have.

                          Comment


                            #14
                            Hope you can find a way to fight this Grommet.

                            I know I'm preaching to the choir here, but I think it is incredulous that community mobility is completely inconsequential. It seems like the more you try to be fit and active, the more you are limited for what help you can get.

                            Apart from a few visiting 10 year olds who found it cool to drive around in the power wheelchair, I don't know of anyone who requests a power chair just for fun. Especially those who do their damndest to use a manual chair when they can, should be applauded for their efforts.

                            This is so short sighted in terms of potential future medical costs, not to mention social, psychological and emotional damage. Add to that what is lost by people not being able to participate in society, contribute to the economy, or support their families and needing to spend so much of their energy and time fighting for what they need.

                            I wish politicians would have to spend a week in a manual wheelchair while debating budgets!
                            Partner of an incredible stroke survivor. Limitations: hemiparesis and neglect (functional paralysis and complete lack of awareness on one side). Equipment: TiLite ZRA 2 and 2GX, Spinergy ZX-1, RioMobility Firefly. Knowledge: relative newbie for high-level equipment (2012), but willing to try to help others who are new with similar limitations (definitely not a guru, but inquisitive).

                            Comment


                              #15
                              Hey Grommet,
                              Don't take no for an answer. Insurance companies will deny, deny, deny, so you need to go through the hoops and keep appealing until it gets to the Administrative Law Judge level. At this level you will have an unbiased judge deciding what you need, regardless of what the insurance company's rules are. I was able to get my insurance (Group Health Medicare Advantage Plan) to buy my EasyStand standing frame this way.

                              At the ALJ level it really helps to have a good attorney on your side. Have you contacted the "Disability Rights" folks I mentioned to you in your other post? They have free attorneys in every state that specialize in helping folks fight for durable medical equipment.

                              Disability Rights California:
                              http://www.disabilityrightsca.org/

                              If you don't get results from Disability Rights California, you can call another state's Disability Rights organization. The DR org in my state couldn't help me, so I ended up with an attorney from Disability Rights Texas! It was sooooo worth it! So please don't give up.

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