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Insurance says NO to more rehab

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  • Insurance says NO to more rehab

    I am C5-7 Incomplete as of Aug 2003. I received the 16 outpatient rehab visits i was allowed with my Blue Care Network Insurance in 2003. The year, of course, started over again in January of 2004. I used up my 16 visits again earlier in the year. I tried to get more outpatient PT from the insurance company. My physiatrist tried several different diagnoses but they said no to all! I am at the point now where I am able to walk with loft strands and an AFO on my right foot. I feel that I desperately need more physical therapy to learn how to walk properly!! I need gait training!! I am so close to being out of this wheelchair completely and know that it would go som much more quickly if I could receive additional PT. There is ABSOLUTELY NO WAY I could pay for it myself!! Does anyone here know of any possible way I could receive more Physical Therapy?

    Is there any gait training studies in your area at a university?

    "Learn from yesterday, live for today, hope for tomorrow"
    ~ Anon
    Emily, C-8 sensory incomplete mom to a 8 year old and a preschooler. TEN! years post.


    • #3
      Ya know, Emi, I'm not sure about gait training studies, but I see my physiatrist at U of M on Monday and will definitely ask him!! Thanks for the idea, I just had NO clue where to start!


        Also, TinaMarie, look in the Exercise forum at the University of Florida Clinical Trial thread, and try to get in touch with those folks. Sounds like you would definitely be a candidate for their program--you'd have to pay your own living expenses, but the training is free.

        If that doesn't work out, keep up the hunt yourself--your physiatrist may not know about all the studies underway.

        Good luck! From what you describe, you're exactly right in saying that you need a lot more PT.


          Does your state have an office of vocational rehabilitation? Try that.


            Some cities have clinics where therapists volunteer time to help people w/ sci. Ours is a nonprofit formed by a local family. My physiatrist told me about it.

            C5/6 incomplete, injured Aug. 2000
            Does This Wheelchair Make My Ass Look Fat?


              Just wanted to post an update to say that I have finally gotten more PT. Unfortunately it's due to a sacral misalignment, but hey, it works. My PT is treating the misalignment, but also helping me with gait training. Hopefully, by the time this PT is done, I'll at least be down to just one loft strand.

              C5-C7 Walking Quad
              C5-C7 Walking Quad - Very Incomplete
              Aug '03


                Hi again Tinamarie

                16 outpatient rehab therapy visits seems like a really small amount. Contact the Customer Service department at BCN and ask how to file a grievance requesting additional visits for health reasons. I think they have to grant you a personal hearing that your doctor and physiatrist should be able to attend with you.



                • #9
                  1.Prepare yourself emotionally.This is hard to deal with. Decide to approach this process with professionalism.15 PT visits is the common standard policy limitation written in the contract without your agreement, and insurance companies are not licensed to practice medicine or write prescriptions for therapy. SCI is a comprehensive condition and they know it.It is a little known fact that they must provide you with your despite the limitations that they tried to put into the policy as long as that care is medically necessary,ie that you are progressing back to the normal state of walking and are not simply exercising your permanently damaged body.Thank you Christopher Reeve for showing recovery and progress post injury 7 or so years? It does happen.

                  Usually, even the most determined individuals drop out of PT because they have their own ways of doing what they want to do when they want to do it and they just move on to other strategies whether that is pool work at their local Y or gym equipment and their own routine-they get independent.There are also new long term places to go like Project Walk in San Diego or Provo Utah or Malaga Spain where you can live and do SCI rehab.You must find the money to go.But by all means, go,if that is what you want.Sometimes it is easier to ask charity for a huge item-"Send me to Spain for 4 months for the special care I need"--than it is for small whiny things."boo-hoo my insurance company won't pay so why don't you give me x dollars for the local rehab?"

                  2.Your doctor is key.Find one who will help you get the PT you need by writing out the prescriptions you require.(Project Walk offers a week long assessment and customized program that you can take home with you. In St Louis, you can get a customized rehab program at Barnes.) The key is to document in quantifiable terms your progress in PT.You can appeal the insurance limitations til the cows come home and get extension after extension but your PT provider will want your cooperation and your doctor's in this process.You will be part of the team in getting this.

                  Discuss with your PT provider your need for a long term relationship-you deserve a discount as a good customer.Sometimes they will discuss reduced payments for a long term client to make it affordable for you in case you pay for some visits. Remember, they are also a business and you are a customer.Put it on your credit card or work out a payment plan with the PT place.Then call your 40 friends and ask them each to send you $20.00 in the mail this month.You can at least get continuity this way until the insurance buggers pay up.Most PT places will go out on a limb with your account at least for a while if they think the insurance will pay up eventually.

                  3.If not, call up some other PT places, you know by now what exercises you do.Consider using a personal trainer for some of your sessions--many out there will even come to your home and they are cheaper than PTs.Just make sure that they are experienced with neuro injuries-Judge their qualifiactions yourself.You clearly are not an idiot. Build your therapy plan,find the services, then find the money.It really is not rocket science, and you should start to realize how to do a lot on your own.

                  4.Keep cool about the money, there are other sources besides the insurance company to keep you going.Use your resources such as your church advisor,local charities, if you really need the money for something like this, you will find it. Sell some possessions,borrow the money from a friend,call up the local newspaper and run a story on your quest with your account number at the bank so people can mail in their check,sell your car to the car cash man. If you need the money, it will come. But you cannot be passive.If you are embarassed, you do not really need the money.

                  5.Are you qualified for Medicaid? Contact your local Independent Living office and speak to a counselor about getting secondary insurance coverage from Medicaid (free)based upon your financial situation.Or, get SSI for your SCI and and reallocate funds--pay for your PT with SSI and get emergency funds from charity to cover your food and utilities.

                  6.But most importantly, learn how to appeal the insurance company's decisions.First, call your doctor and tell him what is going on and that you need a letter of medical necessity.He/she will be happy to give it to you.Next work with the office at the PT provider.
                  Get to know the person who interfaces with the insurance company's approval process.Ask them about their experience with different insurances.No use paying for insurance that doesn't work well. You may find a group coverage through an organization other than what you are currently stuck with through your employer.Find a good lawyer who will help you probono (free).I know these things sound impossible, but it does happen that people step up to help sometimes.You need to learn to ask.The answer will not always be "no"-the odds are against all "no"s.Everyone has to deal with the insurance scam in this country.Everyone.Don't be intimidated by their efforts to limit your visits to 15.That number does not mean anything in a court of law.