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Thread: Finally gonna try to use Medicare to get a chair

  1. #1
    Senior Member Oddity's Avatar
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    Finally gonna try to use Medicare to get a chair

    I've paid out of pocket for 2 Lashers, a Marvel, and an Icon. I'm finally gonna use Medicare to get a new chair. Marvel is sold, Icon to be sold shortly, and one of my Lashers is giving me fits on account of needing a higher back due to an injury. So, I'm replacing it.

    I had my seating eval today. The OT was fantastic. Very knowledgeable about seating, fitting, available chairs on the market and such. There was a DME rep there too. Both really nice guys, but not up to snuff on Medicare billing and reimbursement limits, at all.

    I kept trying to stay focused on the K0005 ultra-lights but they kept driving me to spec out exactly what I wanted and let them deal with reimbursement and such. The OT had a great letter he claims works every time for an ultra-light and the DME kept insisting his billing person gets titanium ZRs and TRs funded via Medicare. Needless to say, I was (and am) super skeptical. I referred them to the Local Coverage Determination, the 'titanium isn't medically necessary' CMS publication, and the 'you can't unbundle titanium as an option' CMS publication, but they shrugged them off and said it won't be a problem.

    I said, 'Whatever, it's your time (and money) that's gonna be wasted, not mine."

    So, we shall see. I'm fully expecting to get a call from the DME with a complete rejection of everything we spec'd out (My ideal ZR), despite their reassurances. They seemed to want to believe they knew more about this process than me, which, is always possible. I guess. Having been in the Medicare/caid actuary field for nearly a decade, and through this process vicariously over and over and over again around here, I kinda doubt it.

    I've already got the order form filled out, ready to hand to him, for an appropriate (and my preferred) K0005 chair to my specifications (Top End Crossfire T6).

    This should be a fun ride. I will shit a literal brick of they pull it off, but I'm calling it now: no fucking way!
    "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

  2. #2
    I concur.

    I think I'm about to admit defeat with regard to getting titanium covered through BCBS, but at least they let me pay out of pocket for the upgrade.

    Good luck on your journey toward a new chair, Oddity... hopefully at them very least it is not as drawn out as mine has been.

  3. #3
    Oddity, Medicare should send you a copy of the approval/rejection report with the problems noted. Theoretically, you then have the right to appeal the decision. There are timelines for the appeal components.

  4. #4
    Senior Member NW-Will's Avatar
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    I'm coming up for a year with this... I'm medicare/medicaid.. and still no further forward.
    The DME and PT spec'd out the chair all gung ho and so far nothing seems to have made it to the medicare desk to even be rejected.
    Are you medicare only? can't you do that pay upfront and then get medicare to pay whatever they will pay once you have the chair routine?

    If your guys pull this off, I'm heading down to Virginia beach to get a chair.. it'll be worth the price of a flight

    As a side note... trying to work with Invacare Topend has been an absolute nightmare. I've even drawn up my own CAD and sent it to them, just to ask if they can even build a chair to the specs.
    Can't get anyone to answer me. Just get some faff back from the rep every once in a while making some spurious argument that it's not possible for some reason, reasons that Tilite had no issue with. As in my current chair design.
    I'm no Tilite fanboy, but have to say at least you can talk to someone there and get answers.. .may not be what you want to hear, but at least they are real answers! Tilite won't make chairs with 27" wheels!

  5. #5
    I don't know a thig about manual chairs so this is way over my head.
    But, just wanted to wish you "Good Luck!"!

  6. #6
    Quote Originally Posted by Oddity View Post
    I've paid out of pocket for 2 Lashers, a Marvel, and an Icon. I'm finally gonna use Medicare to get a new chair. ...
    Could you extend the canes on your Lasher and find an adjustable (or not) fabric back that fits? I might even have one if our sizes don't match up too good. Yea, I save stuff I have no use for.
    Out of curiosity are you on medicare or medicare advantage, not that I know if it will make any difference.
    I have had periodic paralysis all my life. I lost my ability to walk in 2011 beginning with a spinal block, which was used for a hip fracture caused by periodic paralysis.

  7. #7
    Have you gotten a doctor to list this as medically necessary. I don't think anyone gets anywhere on medicare/medicaid without that.

  8. #8
    Senior Member Oddity's Avatar
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    Unfortunately there aren't any credible studies showing titanium specifically has any medical benefits and CMS has published guidelines to this effect. Pre-2014 it was possible, but hard. Since then they've also put out their "unbundling" guidelines so we can't even get it as an out-of-pocket (ABN) option. I'm not fussed about it. I'll share the official EoB info when I get it.

    re: fixing up my Lasher; definitely gonna explore this option. I need a little width as well as height, so it'll be tricky. I've got an old fixed hardware ADI Low-Profile CF in my pile of goodies I'm gonna try to make work. It's 16" wide with hardware custom mounted to fit 15" 1 3/4" tube. Trouble is, the rigidizer bar is too close to allow the back to slide down very far. I might be able to trim the back, and make a custom bit to go below the bar, using the pad to span the distance. I dunno, but it's worth trying to figure out.

    re: why the Top End Crossfire T6; when I look across the market the TiLite ZR has my preferred design as well as options. The closest thing to that in a Medicare friendly K0005 ultralight in aluminum is the T6. It also has all the options I want like welded fixed backrest, strap upholstery (no frame holes!), loop footrest, V front end, CF side guards trimmed to my spec. A number of these are 'no charge' options while the ZR is an upcharge for all of them. I don't need anything special, all I want are straight order form choices. If it lasts 5 years I'll be fine. Not concerned about Invacare or service.
    "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. #9
    With the Crossfire T6 you can taper the seat then again taper front end to get just enough room for your feet.

  10. #10
    Senior Member Oddity's Avatar
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    Quote Originally Posted by ancientgimp View Post
    With the Crossfire T6 you can taper the seat then again taper front end to get just enough room for your feet.
    I was thinking the exact same thing, but they've added new fine print to that section of the order form that says if you taper the seat, then the front end has to be straight, leaving footrest 2.5" less than front taper. Kinda disappointed, but with the standard V front end the footrest = -5" from seat width, which is only .5" wider than what I use now. That's actually a good thing now that I think about it because that opens up enough room for a Freewheel attachment.

    If you know they'll do it upon request, regardless of what the order form says, lemme know!!
    "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

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