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Thread: Justification of new Chair/Insurance question

  1. #1

    Justification of new Chair/Insurance question

    I am covered under BCBS and got a new chair about 2 years ago. It has NOT been refurbished but I am in need of new tires soon. We have replaced bearings a few times out of our own pocket but I'm sure they won't consider that as part of their decision to approve a new chair. I've lost about 50 pounds since I got this chair and my chair cushion/width is about 2 inches bigger than what I need now. I am wondering if I can use the size difference from the weightloss as a justification to get a new chair rather than refurbishing this one? I wanted to get some feedback from you guys before I call the insurance company and DME. Any suggestions or personal experience that you can share would be great!
    DFW TEXAS- T-10 since March 20th, 1994

  2. #2
    just write a great letter of med nec and have your doc sign. point out weight loss and the chair being way to big is putting you at increased risk for sores from bad posture. i get a new ride every 3 usually, i just got a tr after 2 years last july,. wasnt bad, i wrote one apeal letter and boom everything approved down to lx's and d's. same ins for both chairs cigna.
    Bike-on.com rep
    John@bike-on.com
    c4/5 inc funtioning c6. 28 yrs post.
    sponsored handcycle racer

  3. #3
    Yeah, it can be done. I got a new chair after a year. They fitted my original chair in rehab while I was wearing a TLSO back brace, so it was way too big. I was also developing bursitis one my elbow transferring the chair in and out of the car. With the help of a PT and doctor I got the medical justification for a new chair after only having my first one for a year.

    Quote Originally Posted by offroaderswife View Post
    I am covered under BCBS and got a new chair about 2 years ago. It has NOT been refurbished but I am in need of new tires soon. We have replaced bearings a few times out of our own pocket but I'm sure they won't consider that as part of their decision to approve a new chair. I've lost about 50 pounds since I got this chair and my chair cushion/width is about 2 inches bigger than what I need now. I am wondering if I can use the size difference from the weightloss as a justification to get a new chair rather than refurbishing this one? I wanted to get some feedback from you guys before I call the insurance company and DME. Any suggestions or personal experience that you can share would be great!

  4. #4
    Gosh, I've run into every glitch in the book trying to get a custom chair for the second level of our home. My requests to Aetna were considered excluded and a duplicate, luxury item due to my power chair. I exhausted them and me for 9 months - until their contract ran out with my husband's employer. My poor doctor sent several letters of medical necessity to no avail. I was on the phone with an advocate provided by my husbands employer New Year's Eve...lol...still trying, begging in the last hours.

    This year we were only offered Cigna as a carrier. I've worked with the advocate for 3 months going in circles to find a DME that does custom and in network. Finally today, had a three way call with the advocate, Cigna, and Carecentrix reps saying, I will be per-authorized for a custom chair by the end of the week. My power chair will not be considered because in was under Aetna. The problem, they said, is my local DME's providing custom, have been bought out by a larger DME company. Wish I could remember the name of the company, I've heard of them.

    Aetna and Cigna have justification for duplicate items. One I know of is a change in your condition. Yours would be weight I assume.

    I've got my hopes up my chair will come through, this time! In any event, I have a copy or two of letters of medical necessity from my doctors. If you would like, I can post them here for you to tweak to your needs?

    Good luck!!!
    Incomplete, SCI, T1-T8, w/ Arachnoid Cyst. Bilateral shoulder surgeries, 2 on the left, 3 on the right, right forearm surgery for a crushed radial nerve.

    "We can always choose to perceive things differently. We can focus on what's wrong in our life, or we can focus on what's right."
    — Marianne Williamson

  5. #5
    There is a difference in needing a second chair because you can't use your first one than getting a second chair for using upstairs. I have never heard of anyone getting approved for something like that. Since it is just for upstairs and not needed for long term use why not just buy one from ebay. I ask because the original chair I had that doesn't fit is my upstairs chair. It is fine for that, just not appropriate for everyday use. To be honest I can see why an insurance company would find spending 5-6K on a chair for you just to use upstairs excessive.

    ETA: I hope you get your chair, insurance companies suck and you should get every penny you can from them.

    Quote Originally Posted by Charlottes Web View Post
    Gosh, I've run into every glitch in the book trying to get a custom chair for the second level of our home. My requests to Aetna were considered excluded and a duplicate, luxury item due to my power chair. I exhausted them and me for 9 months - until their contract ran out with my husband's employer. My poor doctor sent several letters of medical necessity to no avail. I was on the phone with an advocate provided by my husbands employer New Year's Eve...lol...still trying, begging in the last hours.

    This year we were only offered Cigna as a carrier. I've worked with the advocate for 3 months going in circles to find a DME that does custom and in network. Finally today, had a three way call with the advocate, Cigna, and Carecentrix reps saying, I will be per-authorized for a custom chair by the end of the week. My power chair will not be considered because in was under Aetna. The problem, they said, is my local DME's providing custom, have been bought out by a larger DME company. Wish I could remember the name of the company, I've heard of them.

    Aetna and Cigna have justification for duplicate items. One I know of is a change in your condition. Yours would be weight I assume.

    I've got my hopes up my chair will come through, this time! In any event, I have a copy or two of letters of medical necessity from my doctors. If you would like, I can post them here for you to tweak to your needs?

    Good luck!!!
    Last edited by t8burst; 03-28-2013 at 08:48 AM.

  6. #6
    Quote Originally Posted by t8burst View Post
    There is a difference in needing a second chair because you can't use your first one than getting a second chair for using upstairs. I have never heard of anyone getting approved for something like that. Since it is just for upstairs and not needed for long term use why not just buy one from ebay. I ask because the original chair I had that doesn't fit is my upstairs chair. It is fine for that, just not appropriate for everyday use. To be honest I can see why an insurance company would find spending 5-6K on a chair for you just to use upstairs excessive.

    ETA: I hope you get your chair, insurance companies suck and you should get every penny you can from them.
    If I had a nickle for every time I've heard, " I have never heard of anyone getting approved for something like that", I could buy 2 chairs on eBay!!!

    In my policies, it can be "justified" only because there is no shower or bedroom on the first level or means to move the zoomer upstairs. They will also consider a change in condition. A lesion that developed in 2010 covers that "justification" in the letter of medical necessity. Insurance will not consider my needs outside the home. BUT, I do need it when I can't take the power chair in bad weather. I use a hospital type chair that wrecks me with vibration. I hate it! When I inquired with Aetna, they made it sound like a piece of cake. Ha!

    Cigna has not been easy either, but the power chair will not be a factor, or so I'm told, by the advocate with my husband's employer. I just walk around repeating phrases like, "we'll see", "I don't know", "I don't care" or "so" these days. My family and dog are starting to look at me funny. SCI might not be as bad if there wasn't so much BS in the path.

    I hope my persistence pays off, Tburst, and thanks for your suppport. Surgical intervention is the subject today with my NS. The chair would be urgent post-op. With that up in the air every 6 months after MRI, one boy off to college, another in 4 years, and me battling SSDI, (thanks to a lazy attorney), I'm holding off on the eBay chair for the 3rd level of our house from hell. That level was under constructions when the accident occurred - we have not returned to the project since. I don't care.

    LOL, just got a call, per-authorization is going over the wire as I type, and all of my paper work has been moved, to Medical Mobility, (now National seating and Mobility)! The skinny lady ain't singin til the new wheels roll in...but, if I had a couple of sticks and the strength, I'd do a drum roll! I love it when I can make things happen. So.
    Incomplete, SCI, T1-T8, w/ Arachnoid Cyst. Bilateral shoulder surgeries, 2 on the left, 3 on the right, right forearm surgery for a crushed radial nerve.

    "We can always choose to perceive things differently. We can focus on what's wrong in our life, or we can focus on what's right."
    — Marianne Williamson

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