“The most important thing I did in the final appeal was document my need for an ultra-lightweight. I documented 29 years of stress on elbows, wrists, and shoulders from using crutches and wheelchairs. We also stressed the need to maintain my independence not only in my active lifestyle but in my daily living skills in the home.”
Walter Reynolds, 57, injured at the T9 level in 1970, feels fortunate to be able to live on acreage in central California. He moved to the Santa Maria area in 1980 and not long after landed a good job, where he has been promoted over the years, enabling him to purchase property in a secluded canyon-like area. His lifestyle would be physically demanding for anyone, but for a wheelchair user, appropriate adaptive equipment is critical. He has a long gravel driveway to maintain, a well, a Septic system, and several outbuildings, and he tries to do as much as possible himself.
Problems with shoulder wear and tear from decades of wheeling resulted in rotator cuff surgery, so now he tries to preserve what he has. “There comes a point where you want to use a power chair to save your shoulders.” But not just any power chair works with his lifestyle. He needed a chair with all-terrain capabilities, so he ordered an OmegaTrac by Teftec.
His admittedly hopeful plan was that his insurance company, Blue Cross, which up to that point had provided excellent service, would be able to see his unique need. To make certain they understood, he engaged an Occupational Therapist to do an exhaustive, 20-page summary/analysis of his ADLs and rural lifestyle. Nice try, but didn’t work.
“They should be deciding these cases on a case-by-case basis, but they were unwilling to negotiate,” he says. He feels that Medicare policy, specifically the outdated “in-the-home” restriction, is responsible for his insurance company’s Denial. “Insurance companies are falling back on Medicare policy and using the “in-the-home” language to their benefit in order to deny equipment and save money.”
What galls Reynolds most is that in rehab he was taught to do as much as he can possibly do, and now his insurance company, following CMS’ lead, is doing its best to restrict his lifestyle choices.
While lifestyle restrictions imposed by insurance companies may be understandable to some, how can restrictions placed on our health needs be justifiable? James Parsons, 27, a T6 para for five years took time off from his job in Portland, Ore., to travel to Detroit for a three-week intensive rehab program at the Rehab Institute of Michigan last year. He wanted to maximize the potential of his core muscles and stay in shape for future breakthroughs in SCI restorative therapies.
His father, Roger, had met with Dr. Wise Young in China while researching olfactory ensheathing cells treatment options, and Young had told him the best piece of equipment that James could buy would be a stander, to keep his bones strong, among other health benefits. James ordered an EZ Stand Evolv Glider because it combined exercise with standing and stretching, fully expecting that his insurance company, United Health Care, would see the health benefits and cover the cost. They even knew of someone else who had succeeded in getting UHC to cover this model.
But UHC denied Parson’s initial claim, which set in motion a campaign of letter writing between a very determined father and son and an extremely unresponsive insurance company. The Parsons have been careful to document everything in their seemingly endless appeals process, beginning with an internal appeal, which was denied, and moving on to a second appeal, which was also denied, and, finally, to an external appeal, just denied in April. During this process the Parsons have sent untold numbers of letters and have provided documentation of the benefits of the stander for James’ particular condition based on applicable clinical trials, but UHC, playing the role of institutional ostrich with head-in-sand, stubbornly refuses to acknowledge those benefits.
The irony of all this is that UHC paid for James’ intensive three-week therapy at RIM, where he used the exact same model of stander and where he obtained letters of support from physical therapists who worked with him. Still, UHC would not approve the same stander for use in his home.
Not only does the insurance company’s position not make logical sense, but it does not make monetary sense. UHC was willing to pay $5,000 or more for three weeks at RIM but they refuse to pay for a stander/exerciser that the Parsons would be able to make effective use of for years. And what are the benefits of this particular model of stander? Strong bones, enhanced circulation, improved urinary tract and bowel function, less chance of pressure sores, even some cardiovascular benefit.
Apparently, even though the principle of preventative medical care is universally praised, cost-effective treatment is not high on the list of some insurance companies. The Parsons fully intend to seek help from their state legislators.
As unresponsive as Medicare and insurance companies are, there are other potential flies in the ointment. Janet Nordgren, 34, feels that most of the problems with getting a new TiLite wheelchair can be traced to an equipment dealer that was less than competent. To be fair, part of the blame is
