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What should my PT write for a standing wheelchair insurance request?

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    What should my PT write for a standing wheelchair insurance request?

    I know 9 times out of 10 insurance denies standing wheelchairs. I know of a few that were actually approved. What reasons should I ask my PT to put on my evaluation that might actually give me a chance? I'm a c2 incomplete quad
    My GoPro videos: https://www.youtube.com/channel/UC-J...L-yxxXsTXJuKlg

    #2
    I did my Rehab at Magee in Philly 15 years ago. My doctor , who was Dr. Formal was great at writing everything up and my insurance Blue Cross paid for it immediately. I remember they said it was needed for blood flow/pressure on bones/bowels. I am not sure exact verbiage but a good PT should know in the spinal field. Wish you well and hope it gets approved. try to get a glider standing frame. I have been using them for all these years and my bone density has been good.

    Comment


      #3
      Is your PT RESNA (Rehab Engineering Society of North America) certified in wheelchair and seating evaluation? They should know from that training what to put in the letter that your physician will sign. If you are getting your chair through Medicare, they require that the evaluation be done by a RESNA certified person.

      The reasons given for a standing wheelchair must be medical, not convenience, and for use in the home, not the community. So for example, if you need standing for management of AD, especially when alone, this should be included.

      (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


        #4
        Here’s my PT’s letter that got me an F5 Corpus VS in Massachusetts, 2019 after ~6 months of appeals and help from a pro bono disability lawyer. No dice on the headlights, haha.

        Re: {My Name} MassHealth Appeal

        To Whom it May Concern,

        I am writing this letter on behalf of a mutual client Mr. {My Name} who was in my care while admitted to Spaulding Rehabilitation Hospital after a complete C6 spinal cord injury. Due to his injury Mr. {My Name} is dependent on a specialty power wheelchair for all his mobility both in the home and the community. Prior to his injury Mr. {My Name} was a very active individual participating in a multitude of outdoor activities, as well as working full time as {My Job Title}. Mr. {My Name} was responsible for {Brief Job Description Highlighting Standing Tasks}. It is Mr. {My Name}’s goal to become as independent as possible and has every intention of returning to work and will require the requested medical equipment to fully participate in his job requirements. While at Spaulding Rehabilitation Hospital Mr. {My Name} demonstrated the ability to safely operate the requested equipment without assistance.

        According to medicare.gov (Sept 16, 2018) medically necessary is defined as “health-care
        services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

        F3 to F5 upgrade:
        Time Magazine published an article titled “Sitting is Killing You” and suggests standing as frequently as every 30 minutes. Sitting for several hours a day is unhealthy for able-bodied individuals. Imagine how unhealthy it is for people in wheelchairs to be seated for 12 plus hours a day. According to an article published in the Jan/Feb 2018 edition of Rehab Management those who suffer spinal cord injuries are affected not only by mobility restrictions but also by a sequela of autonomic and metabolic impairments due to primarily being wheelchair bound. Some of these complications include: decreased bone mass, poor circulation, disuse atrophy, contracture, spasticity, pressure sores, impaired bowel and bladder function, and depression. The greatest degree of bone loss occurs within the first year after injury due to significant reduction in weight bearing, resulting in an imbalance in which bone resorption occurs at a faster rate than bone formation, thus increasing the risk for lower extremity fractures. Early intervention is essential to delay theses processes from occurring.

        In the spinal-cord injured population, osteoporosis has been seen on x-ray as early as six weeks after injury. This decrease in bone mineral density typically levels off around two years after the injury. The bone density at this point is about the same as that of a 70-year-old female. About 80% of individuals with chronic spinal cord injury have either osteopenia for osteoporosis. This decrease in bone mineral density puts those with spinal cord injury at significantly greater risk for fractures of the lower extremity resulting in the need for costly surgeries, hospitalizations, and rehab stays. The least costly non-pharmacologic treatment for prevention of osteopenia/osteoporosis is standing since mechanical loading of the bones can help maintain bone density.

        People with spinal cord injury are also at increase risk of pressure ulcers due to prolonged periods of sitting. Concordance with pressure relieving movements is poor amongst this population due to limitations in mobility and sensation. When sitting approximately 50% of body weight is concentrated over just 8% of body surface area. Ischial tuberosity and sacral regions tend to suffer pressure ulcerations the most. These wounds disrupt life, often causing episodes of bothy physical and financial disability. Pressure ulcer care has a significant impact of health care expenses, costing an annual 1.8-2.7 billion dollars a year. Prevention on the other hand has been reported to cost approximately one-tenth of these treatment costs.

        Least costly options were considered while Mr. {My Name} was at Spaulding Rehabilitation hospital such as a static standing frame. Due to Mr. {My Name}’s level of injury and decreased upper extremity strength he can not independently stand in a static standing frame and would surely not be able to stand every 30 minutes as recommended by the research. While at Spaulding Rehabilitation Hospital Mr. {My Name} demonstrated the ability to safely and independently stand for 60 minutes with stable vital signs, improved chest wall expansion which led to improved oxygenation and exercise tolerance. Also, a computerized pressure mapping study was completed with Mr. {My Name} which showed adequate pressure relief in the standing position to significantly reduce the risk of a pressure ulcer when compliant with a pressure relief program.

        Seat Elevator, Light Kit and USB charger
        John Kramer from the Department of Health Systems Administration at Georgetown University In Washington D.C. released a new study which suggests that pedestrian wheelchair users are a third more likely to be killed in a road accident than the general public. Kramer states part of the reason for this increase is, “a person using a wheelchair is lower to the ground.”

        The requested seat elevator will allow Mr. {My Name} to raise his seat up to fourteen inches. This will make him to be more visible to oncoming traffic as well as giving him the ability to see over objects such as snowbanks, shrubbery, and parked cars which are all common features on busy city streets. The requested seat elevator is also a feature that is required for the power wheelchair to go from a sitting to standing position.

        Currently Mr. {My Name} travels independently two and from medical and therapy appointments via accessible public transportation. These appointments are at various times of day and include independent travel at night. The light kit will make him more visible to traffic decreasing his risk of not being seen by a motor vehicle. His nightly travel will significantly increase upon return to work and will frequently be in unfamiliar locations, making increased visibility imperative for his safety.

        Because of Mr. {My Name}’s independent travel to medical and therapy appoints and eventually travel throughout the country for work it is necessary for him to have a charged cell phone with him at all times. In the event of a wheelchair malfunction Mr. {My Name} could be stranded without access to a charged cell phone to call for assistance.

        By denying Mr. {My Name}’s request for a standing power wheelchair you are taking away his right to independently stand and are putting him at greater risk for the abundant list of complications associated with prolonged sitting. Mr. {My Name} being a wheelchair user already is at higher risk for being struck by a vehicle. Denying his request for a seat elevator and light kit increases this risk. Telling Mr. {My Name} that these requested items are not medically necessary is telling Mr. {My Name} that his health and safety are not as important as the general population because he has a spinal cord injury and is a wheelchair user. It is my professional opinion that all of the requested items are medially necessary to prevent costly medical complications, improve his quality of life and increase his overall safety.

        Respectfully,
        {My PT’s Info}
        Last edited by ejl10; 31 Aug 2022, 3:31 PM.
        C5/6 complete (maybe) circa June 2018

        Comment


          #5
          Originally posted by JoeMonte View Post
          I did my Rehab at Magee in Philly 15 years ago. My doctor , who was Dr. Formal was great at writing everything up and my insurance Blue Cross paid for it immediately. I remember they said it was needed for blood flow/pressure on bones/bowels. I am not sure exact verbiage but a good PT should know in the spinal field. Wish you well and hope it gets approved. try to get a glider standing frame. I have been using them for all these years and my bone density has been good.
          I have a glider and it's a Godsend
          My GoPro videos: https://www.youtube.com/channel/UC-J...L-yxxXsTXJuKlg

          Comment


            #6
            Originally posted by SCI-Nurse View Post
            Is your PT RESNA (Rehab Engineering Society of North America) certified in wheelchair and seating evaluation? They should know from that training what to put in the letter that your physician will sign. If you are getting your chair through Medicare, they require that the evaluation be done by a RESNA certified person.

            The reasons given for a standing wheelchair must be medical, not convenience, and for use in the home, not the community. So for example, if you need standing for management of AD, especially when alone, this should be included.

            (KLD)
            I'm not sure but will ask.
            My GoPro videos: https://www.youtube.com/channel/UC-J...L-yxxXsTXJuKlg

            Comment


              #7
              Originally posted by ejl10 View Post
              Here’s my PT’s letter that got me an F5 Corpus VS in Massachusetts, 2019 after ~6 months of appeals and help from a pro bono disability lawyer. No dice on the headlights, haha.

              Re: {My Name} MassHealth Appeal

              To Whom it May Concern,

              I am writing this letter on behalf of a mutual client Mr. {My Name} who was in my care while admitted to Spaulding Rehabilitation Hospital after a complete C6 spinal cord injury. Due to his injury Mr. {My Name} is dependent on a specialty power wheelchair for all his mobility both in the home and the community. Prior to his injury Mr. {My Name} was a very active individual participating in a multitude of outdoor activities, as well as working full time as {My Job Title}. Mr. {My Name} was responsible for {Brief Job Description Highlighting Standing Tasks}. It is Mr. {My Name}’s goal to become as independent as possible and has every intention of returning to work and will require the requested medical equipment to fully participate in his job requirements. While at Spaulding Rehabilitation Hospital Mr. {My Name} demonstrated the ability to safely operate the requested equipment without assistance.

              According to medicare.gov (Sept 16, 2018) medically necessary is defined as “health-care
              services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

              F3 to F5 upgrade:
              Time Magazine published an article titled “Sitting is Killing You” and suggests standing as frequently as every 30 minutes. Sitting for several hours a day is unhealthy for able-bodied individuals. Imagine how unhealthy it is for people in wheelchairs to be seated for 12 plus hours a day. According to an article published in the Jan/Feb 2018 edition of Rehab Management those who suffer spinal cord injuries are affected not only by mobility restrictions but also by a sequela of autonomic and metabolic impairments due to primarily being wheelchair bound. Some of these complications include: decreased bone mass, poor circulation, disuse atrophy, contracture, spasticity, pressure sores, impaired bowel and bladder function, and depression. The greatest degree of bone loss occurs within the first year after injury due to significant reduction in weight bearing, resulting in an imbalance in which bone resorption occurs at a faster rate than bone formation, thus increasing the risk for lower extremity fractures. Early intervention is essential to delay theses processes from occurring.

              In the spinal-cord injured population, osteoporosis has been seen on x-ray as early as six weeks after injury. This decrease in bone mineral density typically levels off around two years after the injury. The bone density at this point is about the same as that of a 70-year-old female. About 80% of individuals with chronic spinal cord injury have either osteopenia for osteoporosis. This decrease in bone mineral density puts those with spinal cord injury at significantly greater risk for fractures of the lower extremity resulting in the need for costly surgeries, hospitalizations, and rehab stays. The least costly non-pharmacologic treatment for prevention of osteopenia/osteoporosis is standing since mechanical loading of the bones can help maintain bone density.

              People with spinal cord injury are also at increase risk of pressure ulcers due to prolonged periods of sitting. Concordance with pressure relieving movements is poor amongst this population due to limitations in mobility and sensation. When sitting approximately 50% of body weight is concentrated over just 8% of body surface area. Ischial tuberosity and sacral regions tend to suffer pressure ulcerations the most. These wounds disrupt life, often causing episodes of bothy physical and financial disability. Pressure ulcer care has a significant impact of health care expenses, costing an annual 1.8-2.7 billion dollars a year. Prevention on the other hand has been reported to cost approximately one-tenth of these treatment costs.

              Least costly options were considered while Mr. {My Name} was at Spaulding Rehabilitation hospital such as a static standing frame. Due to Mr. {My Name}’s level of injury and decreased upper extremity strength he can not independently stand in a static standing frame and would surely not be able to stand every 30 minutes as recommended by the research. While at Spaulding Rehabilitation Hospital Mr. {My Name} demonstrated the ability to safely and independently stand for 60 minutes with stable vital signs, improved chest wall expansion which led to improved oxygenation and exercise tolerance. Also, a computerized pressure mapping study was completed with Mr. {My Name} which showed adequate pressure relief in the standing position to significantly reduce the risk of a pressure ulcer when compliant with a pressure relief program.

              Seat Elevator, Light Kit and USB charger
              John Kramer from the Department of Health Systems Administration at Georgetown University In Washington D.C. released a new study which suggests that pedestrian wheelchair users are a third more likely to be killed in a road accident than the general public. Kramer states part of the reason for this increase is, “a person using a wheelchair is lower to the ground.”

              The requested seat elevator will allow Mr. {My Name} to raise his seat up to fourteen inches. This will make him to be more visible to oncoming traffic as well as giving him the ability to see over objects such as snowbanks, shrubbery, and parked cars which are all common features on busy city streets. The requested seat elevator is also a feature that is required for the power wheelchair to go from a sitting to standing position.

              Currently Mr. {My Name} travels independently two and from medical and therapy appointments via accessible public transportation. These appointments are at various times of day and include independent travel at night. The light kit will make him more visible to traffic decreasing his risk of not being seen by a motor vehicle. His nightly travel will significantly increase upon return to work and will frequently be in unfamiliar locations, making increased visibility imperative for his safety.

              Because of Mr. {My Name}’s independent travel to medical and therapy appoints and eventually travel throughout the country for work it is necessary for him to have a charged cell phone with him at all times. In the event of a wheelchair malfunction Mr. {My Name} could be stranded without access to a charged cell phone to call for assistance.

              By denying Mr. {My Name}’s request for a standing power wheelchair you are taking away his right to independently stand and are putting him at greater risk for the abundant list of complications associated with prolonged sitting. Mr. {My Name} being a wheelchair user already is at higher risk for being struck by a vehicle. Denying his request for a seat elevator and light kit increases this risk. Telling Mr. {My Name} that these requested items are not medically necessary is telling Mr. {My Name} that his health and safety are not as important as the general population because he has a spinal cord injury and is a wheelchair user. It is my professional opinion that all of the requested items are medially necessary to prevent costly medical complications, imdeprove his quality of life and increase his overall safety.

              Respectfully,
              {My PT’s Info}
              Thank you for this info, I hope my PT will be willing to put in a little extra effort for an appropriate letter. I wonder if I write a letter if it would help.
              My GoPro videos: https://www.youtube.com/channel/UC-J...L-yxxXsTXJuKlg

              Comment


                #8
                Originally posted by dontevergiveup View Post

                Thank you for this info, I hope my PT will be willing to put in a little extra effort for an appropriate letter. I wonder if I write a letter if it would help.
                When I applied to grad school, I found that writing the recommendations on behalf of my recommenders and then allowing them to modify as they saw fit produced much better results!
                C5/6 complete (maybe) circa June 2018

                Comment

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