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  • #16
    With the right letter from a PT it shouldn't be a problem. I got BCBS to spring for a TR3 and a SmartDrive.

    Tom

    Originally posted by funklab View Post
    I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

    I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

    BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.

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    • #17
      Originally posted by funklab View Post
      I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

      I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

      BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.
      If you have the money to cover the upgrade I would do so. Your shoulders are much more valuable to you than to use them in a get back or sorts IMHO

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      • #18
        BCBS Association member organizations are independent corporations. What one offers in one state has no bearing on the benefit plans available in others (sometimes even within a single state). E.g. Anthem Blue Cross California, and Blue Shield of California, are 2 completely different companies, with different benefit plans, and are equally separate from Blue Cross Blue Shield of North Carolina. Etc, etc, etc. There is no 'national' BCBS benefit plan. They are licensees of the BCBS Association, nothing more. They're basically franchises with no unifying benefit structure.
        "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

        "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

        "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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        • #19
          Originally posted by djrolling View Post
          If you have the money to cover the upgrade I would do so. Your shoulders are much more valuable to you than to use them in a get back or sorts IMHO
          Oh I will definitely pay for the upgrade if I have to... it's just that the act of repeatedly reaching to my wallet to pull out 15 notes with benjamin franklins face on them is going to hurt my shoulder enough that I'm pretty sure I'll still need physical therapy to at least the tune of $3,000 or so this year... hell the chair is gonna get me to my max out of pocket... I'm vindictive, not self-destructive...

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          • #20
            This issues tracks back to a policy decision / policy interpretation that Medicare made more than a year ago, which is now being followed by other insurance companies.

            Medicare has not indicated any willingness to roll back this policy, so the recourse is to advocate for change by contacting your member of Congress and explaining how this policy will cause you harm or increase the overall costs of healthcare. Of course you always have the option to file an appeal with your insurance company as well.

            Here is a good article from Mobility Management covering this topic: https://mobilitymgmt.com/articles/20.../titanium.aspx

            Good luck!

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            • #21
              The biggest issue I have with that is they're saying K0005 covers all frame materials yet they deny claims for specifically for being titanium. This is because the manufacturers have changed titanium from a discreet product to an "upgrade option" on aluminum frames. Medicare denies the upgrade, on the grounds it's baked into the base code, but manufacturers have hence refused to not classify it an "optional upgrade". Because they want more money for it.

              If they'd remove that as an "option", just make it a different product, the way it used to be, the Medicare logic of "all frames are included in K0005" would work fine. That won't happen though, because the reimbursement isn't high enough to make it worth their while.

              So, there is a problem on both the payer and the manufacturer sides of this equation. Moving titanium to an option was a business decision and has as much to do with why we don't have access to it as the way Medicare decided to classify titanium frames. For the manufacturer quoted in that article to insinuate it's all Medicare screwing us over is a bit disingenuous. The manufacturers could solve this for us, too, but they're protecting their margins. Medicare is doing the same thing, protecting their medical loss ratios.

              Neither side is doing what's best for our needs, frankly.
              "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

              "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

              "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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              • #22
                Originally posted by Oddity View Post
                Neither side is doing what's best for our needs, frankly.
                You sound as if you think insurance companies and DME manufacturers don't care about their customers. They absolutely do.

                To the manufacturer the DME middleman is the customer. To the DME provider the insurance company is the customer. To Medicare the taxpayer is the customer. It's just that the patient isn't anyone's customer, so no one cares about us.

                The evil, ugly, idiotic, horrible subhumans that work at my DME provider (may their souls burn eternally) would have been more than happy to throw me in the chair they have the highest profit margin on and does not care one little bit whether or not the chair works for me or will be unsafe or will fail to fit me at all. They just want me to STFU and do what they tell me to do so they can bill my insurance company. In fact they seem absolutely shocked that I actually WANT something. Like it blows their minds that I not only want a specific chair with precise dimensions that I didn't let them have any input on, but I also want specific wheels, casters, hand rims, etc, etc. I'm not the customer to them, I'm just an inconvenience that stands in the way of them getting paid.

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                • #23
                  You really need a electric chair if you want to save your shoulders. Get a DR. that will help you get started with this. Chairs are replacable your shoulder are not.
                  Art

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                  • #24
                    This is the kind of stuff I'm trying to learn about. The BCBS benefits advisor on the phone can only tell me what codes are. She/he doesn't seem to be plugged in to how they might be used.

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                    • #25
                      Originally posted by funklab View Post
                      I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

                      I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

                      BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.
                      I'm in pretty much the same boat, and I'm tenacious as well. One thing I intend to include is the fact that the extra durability of the Ti under the beating it gets will make for a longer time before I need another chair that they will pay for. I am also working on every way plausible to tie my medical problems in my history to a rationale for a new Ti chair. I have a history of Al and Ti chairs with this company. I can show a change in my treatment with the transition.

                      The biggest problem is if the provider isn't going to get behind me, then I'm on my own to navigate the high seas of insurance approval. They are supposed to be the experts AND my advocate, but they seem so damned lazy that they have given up. So, I can't expect any help from them. Fortunately, my doctor is the best and will be totally behind me on whatever I need her for.

                      Comment


                      • #26
                        Originally posted by t8burst View Post
                        With the right letter from a PT it shouldn't be a problem. I got BCBS to spring for a TR3 and a SmartDrive.

                        Tom
                        Tom, would you be willing to post your letter that worked for you? De-identified and with anything delicate redacted, of course. Even though BCBS organizations from state to state are independent of each other, as Oddity says, it would still help to develop a template to start from. I myself am planning to write a justification letter that will read almost like a review article, with as many literature references as needed.

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                        • #27
                          Originally posted by Tom Borcherding View Post

                          Here is a good article from Mobility Management covering this topic: https://mobilitymgmt.com/articles/20.../titanium.aspx

                          Good luck!
                          I read this article. It was part of my search to understand insurance codes. My NuMotion dealer could probably be really helpful in understanding how this is all applied, if they weren't so apathetic. So, I'm kinda left on my own to figure it all out. What I want to know is if there is any way to code what I need in such a way as to give it a better chance of being covered. Example: back in 2011, BCBS was denying coverage for the Spinergy wheels on the basis that the chair already had wheels and they wouldn't cover another set. Wouldn't even look at it, as a matter of procedure. Once I and my DME guy figured that out, resubmitting with the frame and wheels separately (I'm typing this from memory now, so sorry if I remember what they did incorrectly) got everything covered no problem. This time around, I want to make sure everything is presented so as to get it properly considered. Then, I hope the justification letter can do its work.

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                          • #28
                            Tom already did. Read it. BCBS will follow what medicare does. Pretty simple. If your shoulder already hurt you need a power chair anyway. How I got my one and only pressure sore because my shoulder hurt so bad from pushing manual chair over 25 years ago. If you are paralyzed you should start out with a power chair to start with. Even my SCI DR. agrees with me. She see peoples lives destroyed by shoulder injuries. We live almost as long as anybody else does today.
                            My shoulders got a lot better after I got a electric chair. I got 15 years of pretty much painless shoulders after that. The last 10 years I have paid for the 10 years I didn't have one. Shoulder pain is the worse thing I have ever had. Its a aggravating pain that never goes away.
                            Art

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                            • #29
                              Originally posted by Art454 View Post
                              Tom already did. Read it. BCBS will follow what medicare does. Pretty simple. If your shoulder already hurt you need a power chair anyway. How I got my one and only pressure sore because my shoulder hurt so bad from pushing manual chair over 25 years ago. If you are paralyzed you should start out with a power chair to start with. Even my SCI DR. agrees with me. She see peoples lives destroyed by shoulder injuries. We live almost as long as anybody else does today.
                              My shoulders got a lot better after I got a electric chair. I got 15 years of pretty much painless shoulders after that. The last 10 years I have paid for the 10 years I didn't have one. Shoulder pain is the worse thing I have ever had. Its a aggravating pain that never goes away.
                              I have to say I disagree pretty strongly with your assertion that everyone, even new SCIs should be in a power chair. Early on in my SCI adventure I didn't have enough money to buy a chair out of pocket so that would leave me with no manual chair as backup and an electric chair to start. I would have to get a van to drive, and then get a wheelchair ramp or lift for the van, which are gather are a pretty penny themselves and unless I'm mistaken not covered by medicare. This would mean several tens of thousands of dollars I'd have to beg for instead of buying a $500 used Camry with the last of my savings that didn't get sucked up by deductibles and medical bills and getting back to school the semester after I got out of the hospital. Maybe it's just my lack of imagination, but I can't picture being where I am career or independence-wise if I had to rely on a power chair and a van. Maybe there are chairs with super long lived batteries, but pretty regularly I have had to work 30 plus hour shifts during which time I probably clock north of twenty miles in my manual chair and the maneuverability of a manual is pretty much always going to beat an electric.

                              Then again I've never been big on planning too far in the future. I can't picture being alive much past 50 years old and I'm not terribly far away from that. I think many of us, including me, got our spinal cord injuries because we used and abused our bodies and put them at risk doing dumb (but fun) things. If my shoulders go, they go. Hopefully I have the good sense to keep on top of it and dial back my activity appropriately before they get too far gone, but given my history I probably wont and will probably repeat your mistakes from years ago.

                              If you want to argue that all new SCIs should get a manual chair with a power addon like a smartdrive or something similar, I'll endorse that idea, but I think the flexibility of a manual is critical in getting back to living some kind of reasonable life.

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                              • #30
                                With my bad shoulders I really can regret not getting a tub transfer chair much, much sooner than I did. I never had pain when road racing, but attribute my shoulder issues to constant daily transfers - toilet, tub, car, couch, floor. Got ZX1 about 4 years ago when I could no longer push my manual chair outdoors.

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