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Standing frame refused by insurance company

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    Standing frame refused by insurance company

    Hi,

    I have a couple of question you guys may have experience with and I appreciate all the help in advance.

    I was recently refused a standing frame from blue cross . They told me there's no documented evident that a standing frame will help me. Any of you guys have experience with that?

    Emmanuel
    T7 Incomplete from 1989

    #2
    Did you get a letter of medical justification from your provider? While there is no documented evidence that passive standing will help with osteoporosis, there is good evidence for its use to prevent contractures, reduce spasticity (thereby reducing your need for spasticity meds) and improved bowel transit time. You can appeal the decision, and request that your appeal be reviewed by a physiatrist, who is much more likely to know about these benefits (you have the right to request that the appeal review be done by a specific type of specialist, not just a clerk, nurse, or generalist physician).

    (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


      #3
      under UHC it is accepted.

      They have a new policy as 12/2015.

      I will find and send to you.

      Originally posted by emanshiu View Post
      Hi,

      I have a couple of question you guys may have experience with and I appreciate all the help in advance.

      I was recently refused a standing frame from blue cross . They told me there's no documented evident that a standing frame will help me. Any of you guys have experience with that?

      Emmanuel

      Comment


        #4
        Originally posted by SCI-Nurse View Post
        Did you get a letter of medical justification from your provider? While there is no documented evidence that passive standing will help with osteoporosis, there is good evidence for its use to prevent contractures, reduce spasticity (thereby reducing your need for spasticity meds) and improved bowel transit time. You can appeal the decision, and request that your appeal be reviewed by a physiatrist, who is much more likely to know about these benefits (you have the right to request that the appeal review be done by a specific type of specialist, not just a clerk, nurse, or generalist physician).

        (KLD)
        Here's what the doctor wrote and also what the insurance wrote to me.Please let me know your thoughts
        Attached Files
        T7 Incomplete from 1989

        Comment


          #5
          That is not much of a LMN -- very vague, no citations, multiple misspellings. If necessary, draft an enhanced one yourself citing available literature and have your MD sign. EasyStand may have some examples, but don't copy. KLD said it all as far as the appeal process.

          The RESNA position paper is obviously an important citation.
          Last edited by renard; 13 Apr 2017, 5:34 PM.

          Comment


            #6
            I submitted two LMNs and 9 (yes, NINE) peer-reviewed papers on why dynamic standing frames (EasyStand Glider) help with blah blah blah and my insurance denied it and denied the appeal stating BOTH TIMES that "there is no evidence that static standing frames prevent bone density loss."

            i.e. they focused on only one benefit and ignored the fact that it was not a static standing frame.

            Private for-profit insurance has no incentive to help chronically injured people. We're just loss centers. Their best case scenario is we die.
            T3 complete since Sept 2015.

            Comment


              #7
              Here are some policy statements:
              https://www.unicare.com/medicalpolic...pw_b099008.htm (See Other Conditions, especially paragraph two in that section).
              https://med.noridianmedicare.com/web...ncovered-items

              Medicare (Nordian - 2nd policy statement) seems not to cover standing frames either. It may be an uphill battle.

              Anyone here had a standing frame paid for by Medicare or private insurance?

              Comment


                #8
                I found this after reading this post. attached is a .pdf from united health care .. very interesting as I have them for my medicare ...
                Attached Files

                Comment


                  #9
                  I think part of the problem is the piss-poor justification letter you got from your physician. Look at the attachment above. Their letter needs to address in detail and with great specificity each of the required criteria listed, individualized for you.

                  (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


                    #10
                    Originally posted by GJ2 View Post
                    I found this after reading this post. attached is a .pdf from united health care .. very interesting as I have them for my medicare ...

                    me to but i bought a standing frame in 2003

                    Comment


                      #11
                      Back in the day, probably 1985, my private insurance through the company for which I worked, covered my standing frame...but hey! that was back when dinosaurs roamed the earth. Today...anybody's guess.

                      Comment


                        #12
                        Originally posted by gjnl View Post
                        Anyone here had a standing frame paid for by Medicare or private insurance?
                        Yep, BCBS IL. BUT, and a big BUT...apparently they screwed up some sort of preapproval process with a DME vendor, which they tried to weasel out of. One inbound to me phone call they actually got rather aggressive trying to get me to accept non-payment. I told them it was approved per their process or some such thing (this was over 10 years ago, memory sucks) and ended that call. A week or two later the DME said my account was mysteriously paid by BCBS with no itemized description what the payment was specifically for. It was quite the battle, both by me and the DME that I was working with in concert on this issue. But it did get paid. Thinking back I'm wondering if the heartburn was worth the $$$, but I guess it was after all.

                        Comment


                          #13
                          We had to appeal this 3 times with BSof CA. They finally paid for it. An attorney friend of mine ( she worked for Kaiser a few years ago) said that most insurance companies don't expect the people to appeal so they always deny a claim initially. We appeal everything and usually win in the end.

                          Comment


                            #14
                            I think the justification letter is garbage, but to be honest, the data does suggest that a standing frame is of no medical benefit, so the insurance company might refuse no matter what.

                            Comment


                              #15
                              It all comes down to how well the letter of medical necessity is written. When I was considered for a spinal cord stimulator, the insurance company initially turned down the request. The pain interventionalist rewrote the letter of justification and the same request was approved.

                              Similarly, my physiatrist recommended that I get a standing frame. When I went for an evaluation by a PT, she determined that I would benefit from it. However, since I couldn't pump myself up ( I have a progressive neuromuscular disease) she suggested I get a standing wheelchair. It took the coordinated effort of a RESNA PT, my PT, the physiatrist, the DME, and Permobil, but they apparently crafted a good letter of medical necessity. I was approved for a Permobil F5VS on the first try.

                              Thus, I think that it comes down to the effort put in to the letter.

                              I would suggest you try again.

                              The best of luck.

                              Comment

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