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Thread: Medicare and medical equipment

  1. #1

    Medicare and medical equipment

    My battle to appeal Medicare’s denial of payment for the seat lift on my power wheelchair is going to be an uphill one, at best. The problem began with the manufactures’ marketing. None of the benefits of the seat lifts described in their advertisements fit within the narrow parameters of Medicare’s definition of a medical necessity. Uses such as accessing higher places, speaking eye-to-eye with others, etc. are considered life quality enhancements or conveniences. To be considered medically necessary, the equipment must be useful in helping the person to recover from a medical problem, or to prevent further deterioration of a medical condition. Moreover, Medicare stipulates that the equipment must be primarily or customarily used to treat medical conditions. If the equipment was designed for non-medical purposes, the fact that it may be found helpful in treating a medical problem does not qualify it.

    I have reviewed a couple of appeals cases dealing with Medicare’s denial of payment for seat lifts, and they have been denied all the way up to the top of the appeals process. The denials were all upheld on the “not medically necessary” finding. They stated that all the reasons given for justification were quality of life and convenience issues. Moreover, they cited the manufacturers’ descriptions of uses of seat elevators as supporting the conclusion that are not medical equipment.

    So here I am, getting an elevating seat to spare my shoulders additional damage when transferring, a legitimate medical reason, but the cards are stacked against me because of these precedents.

    I will battle all the way to the top to make clear that Medicare’s position is potentially harmful, and showing by example that there are legitimate medical uses. Then the battle can be taken to the next level, that is, getting Medicare to change its policy. I have not yet determined how that can be done. In the end, it may take political pressure.


    I will appreciate any suggestions.
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

  2. #2
    They would rather pay 1/2 million dollars for a pressure sore than spend a few thousand to prevent one.
    Gov. at its finest.

    Art
    Art

  3. #3
    You can't sell Medicare the idea of a gravity transfer, always transferring down rather than lifting your body up on your deteriorating shoulders? The folks at Medicare are difficult to understand re pwr chairs, every senior citizen gets a Hoveround but a quad sci cannot get an elevating seat. Truly bizarre.

    My wife got a demo model low rider C400 Permobil w elevating seat. We were 1st in contact w company rep who knew the whereabouts of what we wanted. He then recommended DME who worked w us to go through the hoops. We did pay about 3,000 out of pocket and I'm not sure they covered the elevating seat option.

    This is not meant as a criticism of Medicare, we would be bankruopt w/o this program, they are great in paying for long hospital stays, not so good w wheelchairs.

  4. #4
    Ag, I am going to point that out, but that will not matter. They have already ruled that it is not a medical device and even if it does help, that is an incidental use and not a primary and intended use of seat lifts. They do not make exceptions for individuals even if they can prove other wise. The determinations are based on the laws and resultant policies. As one of the administrative law judges stated in his conclusions, "even if my personal conclusion is that the policy is wrong, I can only rule as to whether the policy/criteria have been applied correctly."
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

  5. #5
    Dave just started Medicare in April. They want to take the oxygen concentrator away because he uses it intermittently. He may not need it for a couple weeks, but some mornings coming off the vent for the day his stats drop. Once in a while we run it through his vent.
    He went for a sat eval which was having the same device put on his finger we use at home. Now he has a device to read his sat levels 2 nights in a row. I have no doubt they will be normal.
    So medicare would rather pay for an ambulance,ER and possible admit because if he drops or has trouble breathing my choice will be to call an ambulance.
    I will probably end up blowing my budget and buying on on ebay.
    Sorry to hijack 55. Just put me in mind of what we are going through.

  6. #6
    We were able to get the recline and tilt-in-space (partially) covered by Medicare when we got my mother's new Permobile 3 years ago, but as you say above, there was absolutely no way they would cover the seat elevation, in spite of an excellent letter of medical necessity written by the PT who did the chair evaluation.

    Similar to how Medicare "does not go through the bathroom door:" for covering bathing and toileting equipment, it does not make sense from a functional standpoint to deny items like these as "convenience" or "luxury" items, but that is how their regulations currently work. The person with a disability is getting screwed, and we are spending tax money on golf junkets for Congressmembers....

    (Linda, you are a smart lady. I am sure you can find a way for the recording 02 sat meter to show low blood oxygen levels for a good amount of time each night!!!).

    (KLD)

  7. #7
    The painful thing about this initial rejection is that it was signed by an OT. She may well be violating some of AOTA's ethical canons.

    For example:

    NONMALEFICENCE
    Principle 2. Occupational therapy personnel shall intentionally refrain from actions that cause harm.

    I.Avoid compromising client rights or well-being based on arbitrary administrative directives by exercising professional judgment and critical analysis.

    SOCIAL JUSTICE
    Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.
    Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp & Childress, 2009). In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation in society (Braveman & Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.

    Occupational therapy personnel shall
    A. Uphold the profession’s altruistic responsibilities to help ensure the common good.
    D. Advocate for just and fair treatment for all patients, clients, employees, and colleagues, and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession.
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

  8. #8
    just got a permobil c300 with tilt/recline paid for by medicare

    no go on the seat elevator, however. was advised of this before the purchase.

    was about $2,100

    given the state of health care costs, i'd say it still was a good deal, the submitted claim being about $26,000 i believe

  9. #9
    That's the thing; They submit a claim for 26 grand but are only paid what the Feds will pay. Yet we still have to pay the 20% on the claim submitted.
    Congrats on the chair.

  10. #10
    Having become the world's foremost expert on this specific issue, I am getting a handle on why this situation exists. A claim was filed with Medicare for coverage of an Ibot. The components and functions of the iBot were described in detail. Among the components were the parts for standing, stair climbing, and balancing on two wheels(?). Included was an elevating seat. The Ibot, as a total unit, was determined as primarily non-medical in function. Standing, stair climbing, being able to converse eye-to-eye with others were all judged to be quality of life, employment, and psychological in nature, not medical. Consquently, Medicare concluded that all the individual components are non-medical in nature, including the seat elevator. So they are judging other power wheelchair elevating seats on the basis of the Ibot review and rejection. Incompetence rules!! To make such a wide ranging policy on the basis of a single review, which was flawed to begin with, is outrageous. That is why I am fighting this. I may not win, but they will know they done wrong by the time the battle is over.
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

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