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Thread: BCBS coverage of titanium chair

  1. #11
    Suspended Andy's Avatar
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    I am sure a visit to their offices with a Slurpee cup filled with some rabbit repellent (containing such fine ingredients like putrified egg product, cat food, and various fish oils), and a mishap which results in an unfortunate spill will liven up their day...or month. No need to go so such lengths of fruit baskets and such Just make sure you don't get any on yourself...it's nasty, real nasty

    https://www.bobbex.com/how-and-why-bobbex-works/

  2. #12
    Funklab,

    I am currently dealing with almost the exact same situation as you. The details:

    I am a faculty member at Texas A&M going through BCBS of TX.
    My last two chairs purchased with this insurance were Tilite ZRs, one in 2007, and one in 2011 (the one I am sitting in now).
    I contacted NuMotion, which was United Seating and Mobility the last time they handled my chair purchase.
    I am looking for pretty close to what I have: ZR with Spinergy LX wheels, Ti handrails, carbon side guards, ADI carbon back, carbon side guards.

    I had no problem getting my current chair covered in full, but when I called NuMotion in May, the first words out of their mouths were about how BCBS won't cover Ti, and that I would have to agree to pay the difference out of pocket. Well, I looked up enough articles to see that it has become much harder since 2011, but it isn't impossible. The problem seems to be that the ultralight wheelchair code, K0005, is now a catchall for any ultralight, no matter what it's made of. So, the DME provider can't get anymore money for a Ti chair than for an Al one under that code. NuMotion got burned a couple times and now wants people to sign paperwork saying that they will pay the uncovered difference out of pocket if NuMotion doesn't get approval for the full amount from insurance.

    I don't want to give up that easily, and I am having them draw up a quote to get coverage estimates from BCBS. The tech I have been working with has been taking a ridiculously long time getting back to me and is not responsive to my emails and texts. I suspect this is passive aggressive behavior to try and get me to just go away. I have contacted the local National Seating and Mobility outlet and started the eval process with them as a backup. These are my only two options for Tilite dealers within the BCBS network.

    In talking with the BCBS reps on the phone, I don't believe full coverage is impossible if I write the proper justification. And I am good at that. That kind of writing is my living. I think NuMotion is just being lazy. Just this week, however, the tech emailed me about how they want to bring my case to their Coding Committee (can you believe that's really a thing? I wonder if they have arcane rituals and secret handshakes at meetings...) and see if they can code it right. I think they do have leeway from what I've read. The K0008 and K0009 codes are currently valid codes and might be used to submit for a Ti frame, with the K0108 code for custom accessories.

    TL;DR: yeah, I'm feeling your pain right now. These people piss me off. I'd sure like to have an advocate on the DME side instead of another obstacle, but I'm not giving up.

  3. #13
    I too would very much like to hear from people who are dealing with this issue and have had recent success. Here's hoping we can bump this thread a bit and get some more input.

  4. #14
    Senior Member Oddity's Avatar
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    The issue with K0008 and K0009 codes isn't that they aren't valid codes, under Medicare, rather that there are currently no products classified under these codes. The product classifications for these codes all expired in 2013 (or earlier) and have not been renewed. It's a 2 part system, the code has to be current AND a product classification (for a specific item) has to be currently registered as applicable for that code. Medicare stopped all K0009 product classifications a long time ago, and only currently classify the ultra-light chairs we'd actually want as K0005. You're right, though, that DME margins are the driving reason behind why they don't want to even try, without an ABN signed so they can essentially balance bill you the left over difference.

    You'd have to ask BCBS if they have any current product classifications for K0008 or 9. I bet they don't.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  5. #15
    I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

    I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

    BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.

  6. #16
    With the right letter from a PT it shouldn't be a problem. I got BCBS to spring for a TR3 and a SmartDrive.

    Tom

    Quote Originally Posted by funklab View Post
    I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

    I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

    BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.

  7. #17
    Senior Member djrolling's Avatar
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    Quote Originally Posted by funklab View Post
    I got a denial letter from BCBS for the Ti frame upgrade, but they covered just about everything else, including frog leg casters and Spinergy XLX wheels. I'm writing a letter for my PCP to sign indicating that the extra weight of an alulminum frame (TiLite lists it as about a 3# difference) is likely to worsen my shoulders, for which I have already recently needed PT (with my current titanium frame chair).

    I intend to make it clear that without a titanium frame, I'm likely to require a lot more physical therapy... which I think is probably true, I wheel about 5-8 miles a day in my chair and sling it over my body a half dozen times getting in and out of the car.

    BCBS can play it however they want, but personally I'm pretty certain that if they make me pay an extra $1500 for this chair, my shoulders are going to get a lot worse really quick and require A LOT of treatment that's gonna cost BCBS way more than $1500... but I'm vindictive and dedicated like that.
    If you have the money to cover the upgrade I would do so. Your shoulders are much more valuable to you than to use them in a get back or sorts IMHO

  8. #18
    Senior Member Oddity's Avatar
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    BCBS Association member organizations are independent corporations. What one offers in one state has no bearing on the benefit plans available in others (sometimes even within a single state). E.g. Anthem Blue Cross California, and Blue Shield of California, are 2 completely different companies, with different benefit plans, and are equally separate from Blue Cross Blue Shield of North Carolina. Etc, etc, etc. There is no 'national' BCBS benefit plan. They are licensees of the BCBS Association, nothing more. They're basically franchises with no unifying benefit structure.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  9. #19
    Quote Originally Posted by djrolling View Post
    If you have the money to cover the upgrade I would do so. Your shoulders are much more valuable to you than to use them in a get back or sorts IMHO
    Oh I will definitely pay for the upgrade if I have to... it's just that the act of repeatedly reaching to my wallet to pull out 15 notes with benjamin franklins face on them is going to hurt my shoulder enough that I'm pretty sure I'll still need physical therapy to at least the tune of $3,000 or so this year... hell the chair is gonna get me to my max out of pocket... I'm vindictive, not self-destructive...

  10. #20
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    This issues tracks back to a policy decision / policy interpretation that Medicare made more than a year ago, which is now being followed by other insurance companies.

    Medicare has not indicated any willingness to roll back this policy, so the recourse is to advocate for change by contacting your member of Congress and explaining how this policy will cause you harm or increase the overall costs of healthcare. Of course you always have the option to file an appeal with your insurance company as well.

    Here is a good article from Mobility Management covering this topic: https://mobilitymgmt.com/articles/20.../titanium.aspx

    Good luck!

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