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Thread: Appeal Letter for Titanium Upgrade - help me write one

  1. #1

    Appeal Letter for Titanium Upgrade - help me write one

    Anybody got advice on writing an appeal letter for a titanium upgrade to my new chair?

    I have BCBS, so titanium chairs aren't strictly prohibited, they just don't want to pay for them, and BCBS has to consider use outside of the home, unlikely Medicare.

    I currently have a titanium chair and am trying to get another one. So far BCBS has denied it. Several months ago I had to get physical therapy for several weeks for my shoulders, and they bother me the most when transferring the frame over my body getting in and out of the car several times a day, which I am going to try and use as my main selling point. Obviously having busted shoulders has already cost BCBS some money already and I want to find a way to make it clear that not giving me the titanium upgrade is likely to worsen my shoulders. Weight difference is like 3 pounds, but that's also 33% heavier per the TiLite website...

    My doctor is a cool guy that I know through some work colleagues. I'm pretty sure he will write whatever I tell him to write (and would be more than happy to not waste his time trying to draft a letter).

    Anything yall think would be important to include here?

    Any and all suggestions would be appreciated

    Me:
    35, employed, T8 complete, 11 years post injury.

  2. #2
    Senior Member Oddity's Avatar
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    I guess the obvious is how many you times you lift the chair everyday.

    I don't think there are any other real world (legitimate) advantages you can prove unless it's just that it is lighter for lifting (but the lightest metal chairs today are aluminum alloy and steel alloy, so even saying titanium is "the lightest" available is kinda BS).
    "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

  3. #3
    I found several documents of medical policy for Blue Cross/Blue Shield (BCBS) coverage under Excellus, Anthem, and CareFirst BCBS carriers. All were essentially the same when describing terms of coverage for manual wheelchairs. See the Excellus BCBS policy statement here: https://www.excellusbcbs.com/wps/wcm...6-1c37baa16f90

    Found on Page 1:
    POLICY STATEMENT:
    I: Based upon our criteria and review of the peer reviewed literature
    Wheelchairs are considered medically necessary when used by the patient for mobility in the performance of activities of daily living in his/her residence. (See Policy Guideline, II, Wheelchair Features and Coverage Criteria, for additional criteria for non-standard wheelchairs and mobility devices.)

    Found on Page 3:
    Wheelchairs and coverage criteria
    Ultralight Weight Wheelchairs - Manual
    2. Titanium frame has marginal weight advantage over aluminum frame; considered not medically necessary.

    Perhaps your BCBS carrier has different policy statements, but as I understand BCBS, their coverage policies are all pretty much the same. That said, maybe a physical therapist could make a case that your physician could support to recommend the titanium frame for your use given the condition of your shoulders and additional therapies that may be incurred if you don't use an ultralight weight manual chair.

    Good luck!

  4. #4
    Quote Originally Posted by Oddity View Post
    I guess the obvious is how many you times you lift the chair everyday.

    I don't think there are any other real world (legitimate) advantages you can prove unless it's just that it is lighter for lifting (but the lightest metal chairs today are aluminum alloy and steel alloy, so even saying titanium is "the lightest" available is kinda BS).
    Sure, but if it’s down to the Aero T they approved or the titanium upgrade to TR there’s no argument, the titanium is significantly lighter.

  5. #5
    Quote Originally Posted by gjnl View Post
    I found several documents of medical policy for Blue Cross/Blue Shield (BCBS) coverage under Excellus, Anthem, and CareFirst BCBS carriers. All were essentially the same when describing terms of coverage for manual wheelchairs. See the Excellus BCBS policy statement here: https://www.excellusbcbs.com/wps/wcm...6-1c37baa16f90

    Found on Page 1:
    POLICY STATEMENT:
    I: Based upon our criteria and review of the peer reviewed literature
    Wheelchairs are considered medically necessary when used by the patient for mobility in the performance of activities of daily living in his/her residence. (See Policy Guideline, II, Wheelchair Features and Coverage Criteria, for additional criteria for non-standard wheelchairs and mobility devices.)

    Found on Page 3:
    Wheelchairs and coverage criteria
    Ultralight Weight Wheelchairs - Manual
    2. Titanium frame has marginal weight advantage over aluminum frame; considered not medically necessary.

    Perhaps your BCBS carrier has different policy statements, but as I understand BCBS, their coverage policies are all pretty much the same. That said, maybe a physical therapist could make a case that your physician could support to recommend the titanium frame for your use given the condition of your shoulders and additional therapies that may be incurred if you don't use an ultralight weight manual chair.

    Good luck!
    thanks for the link and doing some research for me. Is this for a BCBS Medicare Advantage plan or something? It mentions specifically that if the wheelchair is necessary only for employment they won’t cover it which would be an absurd statement for a policy like mine that is employer provided. The employer might not care whether I’m comfortable or stylish in my chair but they sure as hell care that I show up to work and am able to get around here.

  6. #6
    Senior Member Oddity's Avatar
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    Quote Originally Posted by funklab View Post
    thanks for the link and doing some research for me. Is this for a BCBS Medicare Advantage plan or something? It mentions specifically that if the wheelchair is necessary only for employment they won?t cover it which would be an absurd statement for a policy like mine that is employer provided. The employer might not care whether I?m comfortable or stylish in my chair but they sure as hell care that I show up to work and am able to get around here.
    https://www.bluecrossnc.com/sites/de...%20Wheelchairs

    That is the BCBS of Norf Cackilacky wheelchair policy statement. Seem to remember that's where you are.

    Here is their policy search page:

    https://www.bluecrossnc.com/provider...medical-policy

    Where ever you are, you can access your plan's policy statements, which is what you'd be arguing against, so it's probably help your case to know exactly what the obstacle is. I wouldn't let a little thing like logic or absurdity guide you when it comes to this crap.
    "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

  7. #7
    Quote Originally Posted by Oddity View Post
    I wouldn't let a little thing like logic or absurdity guide you when it comes to this crap.
    This seems like solid advice... unfortunately.

  8. #8
    Apparently I won't be writing a letter. He sent it off this afternoon already (just messaged him this morning)... told y'all he was a cool guy. Hopefully he wrote it well enough...

  9. #9
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    how old is your current chair?
    Rollin' since '89. Complete C8

  10. #10
    Quote Originally Posted by funklab View Post
    thanks for the link and doing some research for me. Is this for a BCBS Medicare Advantage plan or something? It mentions specifically that if the wheelchair is necessary only for employment they won’t cover it which would be an absurd statement for a policy like mine that is employer provided. The employer might not care whether I’m comfortable or stylish in my chair but they sure as hell care that I show up to work and am able to get around here.
    I didn't have BCBS when I was working, but I had an employer provided health plan administered by a major health insurance company. The insurance company didn't pay for medical care, medication, and equipment, it was actually my employer who paid for these things (lots of very large companies self insure) and the insurance company was just the processor of the claims. Companies who self insure can select levels of coverage they want to offer to employees and health care plans are tailored to what these self insuring corporations see as being right for their types of workers and business. Policies are put together and written by choosing from a menu of options of coverage. Possibly your policy statement is different from the one I found for Escellus Blue Cross Blue Shield.

    I found that if I needed equipment or care that was not covered in the corporation's health care policy statement, I could appeal, and often times the corporation's human resources department would prevail upon the insurance adjusters to cover the things I needed, even though they may have fallen outside of the coverage defined by my employer through the written policy.

    When it comes to health insurance coverage absurdity is normal.

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