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  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!
    "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

  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
    Senior Member Oddity's Avatar
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    Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
    "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

  6. #6
    Quote Originally Posted by Oddity View Post
    Partly true. By signing an ABN form (advanced notification of uncovered costs form from Medicare) Medicare patients CAN pay out of pocket for uncovered options. CMS just requires we know ahead of time what those costs will be, before we decide. I explained the "unbundling" issue, in an earlier post, as to why this doesn't apply to frame material upgrades (like titanium). I could indeed use this ABN form process to pay for the color anodizing myself, but not the titanium upgrade.
    This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.

  7. #7
    Quote Originally Posted by funklab View Post
    This is so absurd. I mean I totally get that insurance companies (Medicare especially) doesn’t want to pay for medically unnecessary stuff. But a frame that is 2# lighter offers at least the potential of benefit, at least let us pay for the upgrade. I double the bright pink anodizing you’re planning on getting is going to put any less strain on your shoulders.
    OK, I'm sure I'm missing a few bricks cause I ain't never been real bright guy!
    But, a chair frame, any material built out of is still a chair frame! If it's coded by CMS as passing their testing it makes no sense it ain't covered!
    Profit! DME's cover their rears with piece by piece billing for everything on a chair.
    They have outside company, in most cases, do their billing to Medicare and insurance companies, right?
    Someone other than end user is one decides what is ordered or billed in their good old time while end user just waits and waits!
    Then here comes the ABN form so DME makes sure they don't lose out a extra penny and that penny turns into any amount.
    I think we the end user should have a form for DME to sign that every day past 90 day Face to Face with getting order for chair ought have pay us! Would that not give them incentive to get on the ball?

  8. #8
    I don't know a thig about manual chairs so this is way over my head.
    But, just wanted to wish you "Good Luck!"!

  9. #9
    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.

  10. #10
    Have you gotten a doctor to list this as medically necessary. I don't think anyone gets anywhere on medicare/medicaid without that.

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