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    BCBS coverage of titanium chair

    My DME (notorious liars and incompetents) are telling me that BCBS "denied" my upgrade to my chair.

    Has anyone had BCBS or any other major private insurance company approve a titanium chair in the past couple years?

    They're saying the disapproved the titanium upgrade and sideguards. This is my first chair with purely private insurance (I have medicare as secondary and beyond delaying this process about 12 months because of National Seating and Mobility's incredible incompetence, confusion and generally douchiness, I knew it wasn't going to contribute to the overall bottom line so I'm not using Medicare).

    I was just in physical therapy for my shoulders, and I have to haul the chair in and out of the car multiple times a day which is the main thing aggravating my shoulders, surely if Titanium chairs EVER get approved mine would. Kinda weird that they don't approve sideguards, but whatever I'll just get the cheapest ones they have, I kind of want to see if I can get someone to fabricate some custom carbon fiber panels for the sidguards anyway.

    They're trying to tell me my copay is a little over $3100 for a titanium TR, which seems a little steep, but I know there is some weirdness about an "allowable amount" rather than a straight up 20% copay. I'm still waiting on the horrible humans at the DME to do their thing and send me an itemized bill, which will undoubtedly be incorrect and require me to remind them of what I actually ordered. I called insurance, and all they can see is that a wheelchair cushion was approved, other than that the person I called didn't see any preauthorization for the chair, but I think if you have an "allowable amount" there is no such thing as preauthorization.


    In addition, has anyone paid out of pocket (ie not through DME provider, but buying online or whatever) for wheelchair options? Depending on how they're calculating what I owe them it might be cheaper to order the chair without wheels and just buy the wheels online or buy the sideguards separately, etc, etc.

    I figure with wheels it wouldn't be a big deal, as long as TiLite was still willing to mount the brakes at an appropriate position for 559 wheels, which is what I plan to purchase, but I'm kinda worried that I can't do this with the sideguards, because the side guard mount feels like it's drilled into the frame on my current ZR (but maybe that's not actually the case, I don't know if this can be added after the fact or not).


    Being a cripple sucks. I learned long ago that you have to be your own physician, and I've got that one down fairly well, but now I have to also be my own DME and insurance billing specialist or I'll never get anything done.

    #2
    So that was a lot of blabbering on, but in short I just meant to ask...

    Has anyone got a titanium chair approved through private insurance in the past couple years?

    What was your experience of this like?

    Comment


      #3
      I have had two chairs covered by BCBS in the last 6 years (minus my deductible). One a titanium ZRA and the other a titanium TR. They covered the frame being titanium but that was about it. Any upgrades I needed were covered by the Vocational Rehab Services in my state, since I work full time.
      Last edited by Brad09; 26 Jul 2018, 12:56 PM.

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        #4
        I have BCBS and was recently told by the seating clinic at Kessler that they always deny titanium. You just have to keep appealing and fighting them. I have a strong letter of medical necessity due to shoulders and a hernia. Kessler's seating clinic does a great job, but they are overwhelmed. I have been waiting nearly a year to receive my chair.

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          #5
          Originally posted by Brad09 View Post
          I have had two chairs covered by BCBS in the last 6 years (minus my deductible). One a titanium ZRA and the other a titanium TR. They covered the frame being titanium but that was about it. Any upgrades I needed were covered by the Vocational Rehab Services in my state, since I work full time.
          Did you go through vocational rehab and then start working full time and that's why they covered upgrades? Or were you already working and voc rehab helped? I never went though vocational rehab after my accident, just went straight back to work but if there is some way to get assistance from a state program I'd definitely want to take advantage of it.

          I have BCBS and my last two seating clinics for chairs they said they pretty much never pay for titanium or better, just aluminum so I never tried.

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            #6
            Sometimes just buying at a discount through an on-line vendor is much less of a headache than dealing with insurance, a DME charging list and then some, and time spent dealing with people who apparently didn't make the cut at McDonalds and ended up peddling wheelchairs. Is the co-pay roughly close to discount price for outright purchase?

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              #7
              Originally posted by Tman9513 View Post
              Did you go through vocational rehab and then start working full time and that's why they covered upgrades? Or were you already working and voc rehab helped? I never went though vocational rehab after my accident, just went straight back to work but if there is some way to get assistance from a state program I'd definitely want to take advantage of it.

              I have BCBS and my last two seating clinics for chairs they said they pretty much never pay for titanium or better, just aluminum so I never tried.
              I was already working when I contacted Voc Rehab to help with my chair. It was a long frustrating process just like anything else, but they came through and covered all the extra carbon fiber and titanium parts for my chair so I could get it as light as possible. A lot of it depends on getting paired with the right counselor when you go through them, and I think I've been pretty lucky in that regard. I would definitely contact them if I were you just to ask.

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                #8
                Originally posted by Andy View Post
                Sometimes just buying at a discount through an on-line vendor is much less of a headache than dealing with insurance, a DME charging list and then some, and time spent dealing with people who apparently didn't make the cut at McDonalds and ended up peddling wheelchairs. Is the co-pay roughly close to discount price for outright purchase?

                Not even close, at least with Medicare. A few hundred $ vs a few thousand.
                "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

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                  #9
                  So they sent me more info, apparently my 20% portion sounds legit(ish) like a real 20% based on only slightly more than list prices. My 20% of the chair, wheels (Spinergy XLX), good stimulite cushion, upgraded slingback (don't know how that's gonna work out), aluminum seat pan, frog legs forks and casters, brakes... and I think that's about it is just under $700.

                  They want me to pay out of pocket
                  $1650 for titanium upgrade
                  $310 for carbon fiber sideguards (the DME said they NEVER cover sideguards, but I assume this is just another of the hundreds of lies they've told me
                  $470 for titanium handrims - this is slightly over sportaid price at a quick glance, but with shipping and whatever, it's probably not worth the hassle of me arguing with it and trying to install myself. And definitely not medically indicated in any way, I'm just hoping for something that doesn't black up my hands everytime I have to push more than 100 yards... and I'm not sure even titanium will do it.

                  All in all it doesn't seem unreasonable, except for the fact that I think BCBS should approve the titanium upgrade.

                  But if I choose to fight it, it will certainly be another year, so is it really worth the $150 a month or so it would take during the prolonged fight to get BCBS to pay for the upgrade??? Idk, I wonder... it's already been an 18+ month process and tbh I'm not sure how close the DME really is to actually submitting the order to TiLite after I hand over the cash. They've dragged their feet (I think it's part volitional, but mostly incompetence and apathy) every step of the way. It's like pulling teeth to get these people to do their jobs and I have to tell them step-by-step how to bill insurance, I have to be the mediator between the insurance company and the DME, passing messages along mostly because otherwise the DME is just going to claim they haven't heard from the insurance company or that it's "illegal" to bill BCBS for a titanium chair, etc, etc.

                  It really rubs me the wrong way to hand over so much cash to these imbeciles... I wonder if I could get them to put me on a payment plan and then order the chair, and then I could default out of spite/hate/abhorrence at their very existence.

                  Comment


                    #10
                    Regardless of which way I end up going, I am definitely planning on sending them a nice fruit basket with a hand written letter in the bottom of it.

                    I fantasize about them reading the letter as their munching down on mangoes and papayas in the office (although they're all such fatasses I should probably just send candy). The letter will start out very thankful and nice, thanking them for all their hard work and how many hours over how many years they've worked on getting me the chair. Then as the letter continues extol their good work and laud their tremendous efforts I will slowly start to drop subtle hints about their incompetence, like "I know how hard you worked to get BCBS to agree to pay for the chair without medicare paying [this is bullshit, I spent a year arguing with them that it wasn't illegal to not bill Medicare if I requested it, as BCBS is primary], and I know how you all aren't used to ordering custom wheelchairs, but i appreciate you going out of your comfort zone to help me out." Then as the letter goes on and on for about a page and a half, by the last couple paragraphs it's clear that the whole thing is a patronizing, passive aggressive insult and indictment of their gross incompetence, without ever saying it clearly. I'll have to work on the exact wording, but I'm thinking about praising them for getting up and going to work in the morning at a job where it takes so much effort and many months to accomplish the simplest tasks that would take minutes at other organizations, and adding that it was a pleasure to use my expertise to deal with the insurance companies as I'm sure they have limited to no experience billing insurances (which obviously is their entire reason for existence).

                    In my fantasy the horrible human beings there are halfway done eating their apple slices when they realize the entire purpose of the letter was to call them an idiot (but in a nice way without actually saying it) and they start to wonder what kind of person sends an nice fruit basket with a hand written letter on nice stationary just to insult them, then start to get paranoid that I might have done something to the fruit.

                    Meh, that's about where my fantasy ends, but it seems reasonable to pull off. It will probably be therapeutic just to write and rewrite the letter until it's perfect, because I'm sure I've got a year or so to perfect it before my chair comes in.

                    My friends and coworkers think the fruit basket/letter idea is stupid and pointless, but I think it's kind of elegant and poetical if your simple minded and vindictive (like I apparently am). Obviously I wouldn't do anything to the fruit... though I can't say my fantasies have never gone a bit darker...

                    But whether or not the fruit basket ever materializes I'm going to lobby vocally and loudly to everyone at my job to take them off of the approved DME list for our insurance and find someone else. If their doors are still open in five years I'm going to feel pretty bad about myself.

                    Comment


                      #11
                      I am sure a visit to their offices with a Slurpee cup filled with some rabbit repellent (containing such fine ingredients like putrified egg product, cat food, and various fish oils), and a mishap which results in an unfortunate spill will liven up their day...or month. No need to go so such lengths of fruit baskets and such Just make sure you don't get any on yourself...it's nasty, real nasty

                      https://www.bobbex.com/how-and-why-bobbex-works/

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                        #12
                        Funklab,

                        I am currently dealing with almost the exact same situation as you. The details:

                        I am a faculty member at Texas A&M going through BCBS of TX.
                        My last two chairs purchased with this insurance were Tilite ZRs, one in 2007, and one in 2011 (the one I am sitting in now).
                        I contacted NuMotion, which was United Seating and Mobility the last time they handled my chair purchase.
                        I am looking for pretty close to what I have: ZR with Spinergy LX wheels, Ti handrails, carbon side guards, ADI carbon back, carbon side guards.

                        I had no problem getting my current chair covered in full, but when I called NuMotion in May, the first words out of their mouths were about how BCBS won't cover Ti, and that I would have to agree to pay the difference out of pocket. Well, I looked up enough articles to see that it has become much harder since 2011, but it isn't impossible. The problem seems to be that the ultralight wheelchair code, K0005, is now a catchall for any ultralight, no matter what it's made of. So, the DME provider can't get anymore money for a Ti chair than for an Al one under that code. NuMotion got burned a couple times and now wants people to sign paperwork saying that they will pay the uncovered difference out of pocket if NuMotion doesn't get approval for the full amount from insurance.

                        I don't want to give up that easily, and I am having them draw up a quote to get coverage estimates from BCBS. The tech I have been working with has been taking a ridiculously long time getting back to me and is not responsive to my emails and texts. I suspect this is passive aggressive behavior to try and get me to just go away. I have contacted the local National Seating and Mobility outlet and started the eval process with them as a backup. These are my only two options for Tilite dealers within the BCBS network.

                        In talking with the BCBS reps on the phone, I don't believe full coverage is impossible if I write the proper justification. And I am good at that. That kind of writing is my living. I think NuMotion is just being lazy. Just this week, however, the tech emailed me about how they want to bring my case to their Coding Committee (can you believe that's really a thing? I wonder if they have arcane rituals and secret handshakes at meetings...) and see if they can code it right. I think they do have leeway from what I've read. The K0008 and K0009 codes are currently valid codes and might be used to submit for a Ti frame, with the K0108 code for custom accessories.

                        TL;DR: yeah, I'm feeling your pain right now. These people piss me off. I'd sure like to have an advocate on the DME side instead of another obstacle, but I'm not giving up.

                        Comment


                          #13
                          I too would very much like to hear from people who are dealing with this issue and have had recent success. Here's hoping we can bump this thread a bit and get some more input.

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                            #14
                            The issue with K0008 and K0009 codes isn't that they aren't valid codes, under Medicare, rather that there are currently no products classified under these codes. The product classifications for these codes all expired in 2013 (or earlier) and have not been renewed. It's a 2 part system, the code has to be current AND a product classification (for a specific item) has to be currently registered as applicable for that code. Medicare stopped all K0009 product classifications a long time ago, and only currently classify the ultra-light chairs we'd actually want as K0005. You're right, though, that DME margins are the driving reason behind why they don't want to even try, without an ABN signed so they can essentially balance bill you the left over difference.

                            You'd have to ask BCBS if they have any current product classifications for K0008 or 9. I bet they don't.
                            "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

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                              #15
                              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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