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Thread: Insurance and TiLite ZRA2

  1. #1

    Insurance and TiLite ZRA2

    I received a letter from my insurance company approving a wheelchair and then denying 90% of the features, lol.
    No power assist because I have not been in a chair for 1 year yet.
    No reinforced frame--because they want to wait a year on the wheels

    I could go on and on.

    The icing on the cake----the claim was reviewed by an OB-GYN!!!!
    WTF? I am appealing on principal based on the medical speciality of the reviewer.

    And for this BS I pay huge premiums and carry a rider for DME.
    Every day I wake up is a good one

  2. #2
    oh boy . . .
    Chas
    TiLite TR3
    Dual-Axle TR3 with RioMobility DragonFly
    I am a person with mild/moderate hexaparesis (impaired movement in 4 limbs, head, & torso) caused by RRMS w/TM C7&T7 incomplete.

    "I know you think you understand what you thought I said, but what I don't think you realize is that what you heard is not what I meant."
    <
    UNKNOWN AUTHOR>

  3. #3
    Senior Member wheeliecoach's Avatar
    Join Date
    Dec 2005
    Location
    East Haven, CT
    Posts
    2,600
    Sounds like when I was trying to get a stander....it was reviewed (when I appealed) by a plastic surgeon.
    "Unless someone like you cares a whole awful lot nothing's going to get better. It's not." - Dr. Seuss

  4. #4
    when we file an appeal it is reviewed doctor to doctor in the same subspeciality--that is a real plus.

    The botox for my arm was reviewed by a internist but review was by a physical medicine and rehab doctor.
    Every day I wake up is a good one

  5. #5

    Appeal Hell

    After 45+ days and a request for an extension, my insurance upheld their denial of my TiLite with power assist wheels. They will pay for the TiLite but not the reinforcement or the power assist wheels.
    If I take a non-reinforced frame, and am approved for power assist wheels later, the frame warranty will be void. Can a TiLite ZRA be reinforced at a later date to preserve the frame warranty?

    My insurance carrier is using Medicare Guidelines that require me to use a manual wheelchair for 1 year--to fail and demonstrate upper extremity issues and at 1 yr they will reconsider authorization.

    I have had 3 shoulder surgeries, an ulnar nerve transposition, and 2 carpel tunnel surgeries. We have demonstrated significant upper extremity issues and the carrier covers botox every 3 months for UE spasticity.

    Has anyone ever faced this type of denial and won on appeal? Right now my mobility is close to zero. I have been told in writing that a chair to cover outside the home and work is a convenience item.

    We are moving onto a Stage 2 appeal. Suggestions anyone?

    I am looking for logic in a world where none exists.... the insurance industry
    Every day I wake up is a good one

  6. #6
    How unbelievably stupid they won't cover this considering your medical history. Without a doubt I would continue the appeal. There has to be sanity at some level. Then again with our medical insurance industry, maybe not.

  7. #7
    My only suggestion is to get evaluated by a highly renowned seating clinic. I have read only they have good success with Medicare. Off the top of my head, I don't know any, but several have been mentioned on CC threads.
    Chas
    TiLite TR3
    Dual-Axle TR3 with RioMobility DragonFly
    I am a person with mild/moderate hexaparesis (impaired movement in 4 limbs, head, & torso) caused by RRMS w/TM C7&T7 incomplete.

    "I know you think you understand what you thought I said, but what I don't think you realize is that what you heard is not what I meant."
    <
    UNKNOWN AUTHOR>

  8. #8
    Senior Member grommet's Avatar
    Join Date
    Aug 2008
    Location
    California
    Posts
    2,691
    I gave up, I couldn't keep fighting the system. I saved for five years bought my Tilite TR last June and in two months I will have it paid off.

    My powerchair, an Invacare TDX SP has been out of service with a broken right motor for more than a year. DME was total crap. They took forever getting the paperwork through to insurance and when I contacted DME (months went by - they did not contact me), the said insurance had denied the claim because the left motor had already been replaced.

    Uh yeah .. yes it was, when it broke. This is the right motor that is broken. "Oh.", says crappy DME lady on phone. I asked about them re-applying, she said some confusing things and I never heard from them again.

    I cannot fight with insurance and DMEs anymore. They win. I can't take it. Buying all my own stuff now. By the way, my income is $845 a month, disability. I'd rather go hungry so I can buy parts than have to humiliate myself and keep begging my DME for anything.

    The DME is Wheelchairs of Berkeley. I cannot begin to tell the stories.

    Sorry about your insurance trouble.

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