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    New Insurance Question

    I currently have an Invacare A4 rigid frame wheelchair. It's relatively heavy weighing around 35-40 pounds. I got this chair through my insurance company when I was working with a previous company. I am no longer working there and have different insurance now. I've only had my chair for two years. I'm wondering if I could try to get a new light weight chair through the new insurance company. I know I've heard you have to have your chair for five years before getting a new one but I wondered if this is a different circumstance. I'm not sure if they can look and see that I've only had mine for two years. Does anyone have any experience with something like this?

    #2
    Originally posted by Ethant91 View Post
    I currently have an Invacare A4 rigid frame wheelchair. It's relatively heavy weighing around 35-40 pounds. I got this chair through my insurance company when I was working with a previous company. I am no longer working there and have different insurance now. I've only had my chair for two years. I'm wondering if I could try to get a new light weight chair through the new insurance company. I know I've heard you have to have your chair for five years before getting a new one but I wondered if this is a different circumstance. I'm not sure if they can look and see that I've only had mine for two years. Does anyone have any experience with something like this?
    The five year rule is a Medicare guideline that many insurance companies model. But, even Medicare isn't stuck hard fast to that rule. If your physician and a physical/occupational therapist feel that you situation has changed and you no longer have the strength and ability to push and manage your heavier manual chair, they can make a case (documenting the changes you have experienced) to your insurance that you need a different wheelchair.

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      #3
      shouldn't be a problem.
      Bike-on.com rep
      John@bike-on.com
      c4/5 inc funtioning c6. 28 yrs post.
      sponsored handcycle racer

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        #4
        Originally posted by fuentejps View Post
        shouldn't be a problem.
        Im being told by my vendor that the new insurance company would ask how I'm getting around now and once they find out what I have then they'll deny it.

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          #5
          I have been told by my doctor, my DME vendor and Medicare that status change (change in function) will get me a new chair, even at 2.5 years. I've also been told that Medicare will take care of a manual chair or a power chair - not both, and to let Medicare get the power chair because so much more expensive.

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            #6
            get a new vendor. your not obligated to share that info
            Originally posted by Ethant91 View Post
            Im being told by my vendor that the new insurance company would ask how I'm getting around now and once they find out what I have then they'll deny it.
            Bike-on.com rep
            John@bike-on.com
            c4/5 inc funtioning c6. 28 yrs post.
            sponsored handcycle racer

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              #7
              Originally posted by fuentejps View Post
              get a new vendor. your not obligated to share that info
              Insurance company is also not obligated to buy you a new wheelchair though.


              You've probably got a good chance if you've got a good reason. If I was you I would think really hard about all the reasons why your old chair doesn't work for you and how it cannot be modified to work for you, necessitating a new chair and get a doc to write that in a note with any input from the PT you are working with to get you the chair.

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                #8
                I've been told by my DME that the insurance companies do share this data, so your new company probably knows that your chair is only 2 years old. That said, if circumstances change, you need a new chair. So, here's what you do. You go to your doctor, but look really pathetic and weak when he sees you. Complain that you have no energy because it is so hard for you to push this chair around. Just demonstrate difficulty with your chair. Ask that he put in a request for a lighter chair. The doctor doesn't care that much so they'll almost always put in the request just because you ask.

                When the doctor puts in the request, you will probably get sent to a consult with PT. Again, act even more pathetic. You only see this PT once, so who are they to know how strong you are and what your balance and energy issues are. Just don't do the "look how good I am" and instead do the "look how difficult this is and how tiring". By weak I mean you got to sell that you can barely push around the house, especially if it's carpeted. Demonstrate this by pushing but only use half arm motions (for a quad that is usually reaching back and pulling on the wheel until you reach a top stroke, but do not keep going into the down stroke). Do short strokes, at a quicker pace, trying to show how short the roll is (they have no idea you are pushing more often than you need to), control the speed every time you grab the push rim, keeping the chair from speeding up or gliding on its own. You need to do this from the moment you park your car until you drive away. All that time, you are a quad who is having difficulty.

                Rather than say you need an ultra light. You ask the PT, "are there chairs that are a lot lighter and would I have an easier time pushing them?" Now here's the BIG sell. They will probably have a DME bring some sample chairs out (or make an appointment for this) and you MUST NOT be super transfer guy. Struggle a little when moving your legs. Transfer with a little difficulty and even accept some help, if offered. Then when you get into the ultra-light don't act like super quad. You still have to struggle in your strokes, but this time let the chair roll between strokes and don't slow it down when you grab the push rims. You can show that with every stroke, you go twice as far, or even more. (practice these two different strokes if you need to to make them look natural).

                It really isn't very hard to do this and have the PT and DME (who WANTS to sell a new chair) conclude that you are much better off in the ultralight, without you ever saying anything. And don't ask any questions about any part of using the chair outside of moving around your house while the PT is there. The PT is qualifying you for the best chair for your HOUSE, not for you to play basketball or do anything active. When you are alone with the DME, you can discuss all you want about which chair is perfect for you and all your activities. With the PT, the main thing you want is their recommendation for an ultralight class of wheelchair, which NORMALLY isn't prescribed to quads, because it is seen as a chair for sporty activities, not for around the house and perhaps not even appropriate for a quad. You are convincing the PT that it isn't about how it looks, it is that it actually works for you much better and that it can be set up so that it isn't dangerous. Like the you can ask if it can be made so it isn't very tippy and if there are brakes that are easy for you to use. Again, that is all for the PT. Once they recommend the ultralight, then you will get approved. AFTER you get approved, you can get together with the DME and order whatever you want that the DME can get through under the constraints of the approval.

                To summarize, you are convincing your doctor a little, and the PT a LOT, that the ultra-light is a medical necessity, because the old chair is just too difficult and tiring. And, this is ACTUALLY true, it is just that you need to do a little acting to convince them who don't have a clue what it's really like. Just as an example, when I used a 40 lb chair, I needed grips on my push rims and would go maybe 5 ft between pushes. With a 25 lb chair, I didn't need any grips on the rims and I would go about 10 feet or more with each push. So, it is a radically beneficial difference. You just have to sell that it is NECESSARY for every day life, not for pushing out in the park.

                Quads have a really easy time selling a need for things because no one really knows how capable you are. there are C7 quads who need help with transfer, and C7's who use a transfer board, and C7's who independently transfer up height differences with ease. So, a PT who doesn't know has no clue what you're really capable of. And the insurance approval people know even less. When you say I can't do something, there isn't any way for anyone to say sure your can. Now, I am not telling you to lie, or commit fraud. I am just saying you don't have to show how strong and capable you are.
                C-6/7 incomplete

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                  #9
                  It all comes down to lmn, write it yourself then ask doc to sign. I never use a pt just my sci doc.
                  Bike-on.com rep
                  John@bike-on.com
                  c4/5 inc funtioning c6. 28 yrs post.
                  sponsored handcycle racer

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                    #10
                    Kulea: You have written the book on how to be an activist!! Love your post. So true!

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                      #11
                      Originally posted by fuentejps View Post
                      It all comes down to lmn, write it yourself then ask doc to sign. I never use a pt just my sci doc.
                      Have you purchased a chair using Medicare? I just completed the process and here are the hoops you have to jump through.

                      Medicare requires that your doctor write an order for you to see an occupation or physical therapist for an evaluation for a wheelchair. The doctor must also provide the therapist and Medicare with clinical notes that support the need for a manual or power wheelchair.

                      The physical or occupational therapist does an examination, asks questions about your abilities and other physical issues. During this evaluation, you may be pressure mapped for a new cushion, especially if the type you have been using isn't working for you. During this evaluation, the therapist will invite a durable medical supplier representative, with whom he/she regular works. That representative will bring a couple of sample chairs to the evaluation to get a sense of your needs.

                      The therapist writes a summary of your physical requirement and a prescription for the type of chair and particular features you require. The evaluation summary and prescription must be signed by your doctor and returned to the therapist and the supplier. You are not required to use the supplier who attended yout evaluation. Whatever supplier you choose then works with you to get a chair that will serve your needs, orders the chair, delivers it, and makes any adjustments necessary.

                      It is a long drawn out process and more and more insurance companies are adopting the Medicare model. The first physical therapist I called for the wheelchair and seating evaluation did not have any appointments available for 4 months. I was fortunate and got an appointment with another therapy group in one month. The process can take 2 to 6+ months before you actually have a chair delivered to you.

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                        #12
                        no, but we are discussing private ins not medicare. I've never went through anything like you described with private ins. I complete the order form, review with dme, they get quote from mfr and then submit for approval with lmn. then wait for approval. I think the dme is where things go south.........
                        Originally posted by gjnl View Post
                        Have you purchased a chair using Medicare? I just completed the process and here are the hoops you have to jump through.

                        Medicare requires that your doctor write an order for you to see an occupation or physical therapist for an evaluation for a wheelchair. The doctor must also provide the therapist and Medicare with clinical notes that support the need for a manual or power wheelchair.

                        The physical or occupational therapist does an examination, asks questions about your abilities and other physical issues. During this evaluation, you may be pressure mapped for a new cushion, especially if the type you have been using isn't working for you. During this evaluation, the therapist will invite a durable medical supplier representative, with whom he/she regular works. That representative will bring a couple of sample chairs to the evaluation to get a sense of your needs.

                        The therapist writes a summary of your physical requirement and a prescription for the type of chair and particular features you require. The evaluation summary and prescription must be signed by your doctor and returned to the therapist and the supplier. You are not required to use the supplier who attended yout evaluation. Whatever supplier you choose then works with you to get a chair that will serve your needs, orders the chair, delivers it, and makes any adjustments necessary.

                        It is a long drawn out process and more and more insurance companies are adopting the Medicare model. The first physical therapist I called for the wheelchair and seating evaluation did not have any appointments available for 4 months. I was fortunate and got an appointment with another therapy group in one month. The process can take 2 to 6+ months before you actually have a chair delivered to you.
                        Bike-on.com rep
                        John@bike-on.com
                        c4/5 inc funtioning c6. 28 yrs post.
                        sponsored handcycle racer

                        Comment

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