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Thread: Just got turned down for new powerchair

  1. #1
    Senior Member grommet's Avatar
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    Just got turned down for new powerchair

    It's going to be a fight. They're claiming I don't meet the needs for it under their rules. MediCal paid for a Quickie S626 with tilt-in-space, five years later they paid for my Invacare TDX-SP with the same set up but the insurance changed and now it's MediCal/SF Health Plan and suddenly I no longer meet the requirements. Sigh. I wonder how long this fight is going to take and if I can handle it. I also wonder if there is some kind of advocate I can reach out to. Does anybody know about that?

  2. #2
    Quote Originally Posted by grommet View Post
    It's going to be a fight. They're claiming I don't meet the needs for it under their rules. MediCal paid for a Quickie S626 with tilt-in-space, five years later they paid for my Invacare TDX-SP with the same set up but the insurance changed and now it's MediCal/SF Health Plan and suddenly I no longer meet the requirements. Sigh. I wonder how long this fight is going to take and if I can handle it. I also wonder if there is some kind of advocate I can reach out to. Does anybody know about that?
    Why do you need a power chair?, you look like a para to me, at least in your avatar.
    "Life is about how you
    respond to not only the
    challenges you're dealt but
    the challenges you seek...If
    you have no goals, no
    mountains to climb, your
    soul dies".~Liz Fordred

  3. #3
    What have you done so far? Prescription from doctor with letter of medical necessity for power chair? Evaluation/specification of chair from a physical or occupational therapist? Other?

    All the best,
    GJ

  4. #4
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    Hello Grommet, Medicare would not payfor a sm. scooter for me. i am considered a para. even though i walk with a walker and have TM. i have a wheelchair but i cant wheelmyself at fleamarkets and outside craftshows. i had my outer rim taken off my wheelchair to get in my bathroom and kitchen. my spine dr. said its because i have use of my arms. from what i was told not by that dr. but acouple of friends i could order a wheel chair. but the scooter was only 700dollars. i know a good wheelchair would cost them more . i didnt fight it

  5. #5
    Grommet, is that a Medicare HMO? Are you not now on Medicare since you have been injuried for so long? Normally you would be on Medicare as your primary and Medi-Cal as your secondary at this point.

    Medicare has signficantly tightened up the rules on power chairs in the last few years, and many other insurance companies use the Medicare standards. They will approve a power chair ONLY if you cannot get around inside your home with a manual chair. Community mobility is completely inconsequential for them, so if you are saying you need a power chair to go to the store, school, or work, or just to get around in your neighborhood or town, and can still get around in your house with a manual chair at all, you are going to get turned down.

    In addition, you must have a power chair prescribed for you by a therapist who is certified by RESNA. If you try to just go through a DME who is not RESNA certified, or just with a prescription from your provider, you will be out of luck.

    You are entitled to appeal, but the chances of you winning under the conditions above are slim to none.

    (KLD)

  6. #6
    Super Moderator Sue Pendleton's Avatar
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    Now I see why my physiatrist was pushing me to go for a new powerchair first. Guess carpetting does have its uses. Previously Between the FEP/Medicare and Tricare I got a new power and manual as needed. I think my last manual, currently falling apart, was paid for by Medicare because of the width of the halls at the Capitol and Government offices in Annapolis.

    I was going to ask if anyone has links to the Medicare areas for chairs and PT for 2013? I understand PT is being cut again and even the work around at teaching hospitals attached to the rehab outpatient area is going.
    Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow."

    Disclaimer: Answers, suggestions, and/or comments do not constitute medical advice expressed or implied and are based solely on my experiences as a SCI patient. Please consult your attending physician for medical advise and treatment. In the event of a medical emergency please call 911.

  7. #7
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    I have a medicare replacement plan. And hey gave me an advocate to advocate for my needs. If you have a medicare replacement plan i would ask for an advocate. I hope this helps.

  8. #8
    Quote Originally Posted by Sue Pendleton View Post

    I was going to ask if anyone has links to the Medicare areas for chairs and PT for 2013? I understand PT is being cut again and even the work around at teaching hospitals attached to the rehab outpatient area is going.

    This is an important question....

    Starting this fall, outpatient PT/OT at a hospital based facility will start counting towards the yearly capped Medicare max allowed. Therapists at hospital based facilities will STILL be able to apply for extensions/exemption of this cap while you are doing therapy at hospital based facilities, but this of course is a bit unwieldy. However, I had not realized that this exemption expires in December, unless it is extended by the government. I think the exemption is linked to the same threatened 27.4% decrease in Medicare reimbursement to doctors that happens every year.

    http://www.aota.org/News/AdvocacyNew...-for-2012.aspx

  9. #9
    Quote Originally Posted by SCI-Nurse View Post
    Grommet, is that a Medicare HMO? Are you not now on Medicare since you have been injuried for so long? Normally you would be on Medicare as your primary and Medi-Cal as your secondary at this point.

    Medicare has signficantly tightened up the rules on power chairs in the last few years, and many other insurance companies use the Medicare standards. They will approve a power chair ONLY if you cannot get around inside your home with a manual chair. Community mobility is completely inconsequential for them, so if you are saying you need a power chair to go to the store, school, or work, or just to get around in your neighborhood or town, and can still get around in your house with a manual chair at all, you are going to get turned down.

    In addition, you must have a power chair prescribed for you by a therapist who is certified by RESNA. If you try to just go through a DME who is not RESNA certified, or just with a prescription from your provider, you will be out of luck.

    You are entitled to appeal, but the chances of you winning under the conditions above are slim to none.

    (KLD)
    So you are saying wreck your shoulders then be put in a nursing home......sounds just like obama care....that will save alot of money in the long run huh?....my as well give us a shot and let us go out in piece.

    Art
    Art

  10. #10
    Quote Originally Posted by Art454 View Post
    So you are saying wreck your shoulders then be put in a nursing home......sounds just like obama care....that will save alot of money in the long run huh?....my as well give us a shot and let us go out in piece.

    Art

    This has nothing to do with ObamaCare. This was the Medicare requirement before Obama was in office. So I guess it is "BushCare".....

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