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Thread: Recent Accident to My Son

  1. #81
    Baclofen is the most commonly use drug for spasticity in SCI. It should supplement, but not replace, standing, stretching, and proning as methods of decreasing spasticity.

    It is rare that spasticity gets better over time. In fact, it usually increases over the first year, and then stay stable, but some may find it actually gets worse with aging. Other factors such as irritants (pressure ulcers, UTIs, etc.) can make spasticity suddenly worse as well. Sometimes increased OR decreased spasticity can be associated with a syrinx.

    Other medications (which may be more or less sedating for the individual person) used for spasticity include tizanadine (Zanaflex), dantrolene sodium (Dantrium), and diazepam (Valium). Clonodine is sometimes used in combination with either Zanaflex or Baclofen.

    A baclofen pump is not something to be done lightly, and is usually seen as a last resort. While this route may offer fewer sedating side effects, it also is not without its own risks (overdose, infection, and problems with the pump requiring repeated surgeries are the most common). It also requires an ongoing relationship with a physician and clinic expert in doing the refills and adjustment of the pump necessary. Refills are generally required at least every 3 months.

    (KLD)

  2. #82
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    Thanks, for the information about the baclofen. I'm in Atlanta for the long weekend. Brian is in the day program at the Shepherd Center. A tentative completion date of June 22 has been set. After that we're still undecided about the next step. Cheesecake put me in contact with the people at the Kennedy Krieger Institute for continued Activity Based Restorative Therapy. Brian's name is on the waiting list so we'll see what their recommendation is on timing.

    I also wanted to update everyone on transportation expense issue. When this thread started one of the issues discussed was the fact that Blue Shield of California refused to pay for the cost of transportation from Phoenix to Atlanta. I've been working on this for several weeks now. What I noticed one day was that Blue Shield paid the ambulance claim for moving Brian from St. Joseph's Hospital to the Phoenix airport. I didn't realized that this expense was not included in the American Aerovac bill that I had paid. Anyway, when I saw that the ambulance claim had been approved and paid by Blue Shield I thought will why don't I have American Aerovac submit a claim for their service. I called American Aerovac and asked them to submit a claim. After waiting several weeks and resubmitting the claim 6 times Blue Shield finally made a determination that they were denying the claim because:

    "Based on the documentation provided, the medical need for this was not established"

    The documentation that I submitted was a letter from the doctor at St. Joseph's in Phoenix that says an air ambulance is the only acceptable way to transport Brian to Atlanta from Phoenix, the medical log from American Aerovac and the Blue Shield claim form. Brian's case worker at the Shepherd Center is now going to help me justify why the air ambulance was absolutely necessary. She said that she's going to submit a short but powerful letter that shows that an air ambulance was necessary and cost effective. Brian's doctor at the Shepherd Center has also agreed to submit a letter as the receiving doctor that says the air ambulance was the only medically acceptable method of transport.
    I think we're going to get reimbursed for the transportation because the reason for the denial is just wrong. I don't think that denying the claim based on not being medically necessary is defensible. I would have preferred that the claim had been paid but I was pleased when the claim was denied for not being medically necessary. I believe we can show that the air ambulance was necessary.

    Roger
    Last edited by Roger; 05-27-2007 at 08:10 PM.

  3. #83
    Senior Member Jesse's Mom's Avatar
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    Quote Originally Posted by Roger
    Thanks, for the information about the baclofen. I'm in Atlanta for the long weekend. Brian is in the day program at the Shepherd Center. A tentative completion date of June 22 has been set. After that we're still undecided about the next step. Cheesecake put me in contact with the people at the Kennedy Krieger Institute for continued Activity Based Restorative Therapy. Brian's name is on the waiting list so we'll see what their recommendation is on timing.

    I also wanted to update everyone on transportation expense issue. When this thread started one of the issues discussed was the fact that Blue Shield of California refused to pay for the cost of transportation from Phoenix to Atlanta. I've been working on this for several weeks now. What I noticed one day was that Blue Shield paid the ambulance claim for moving Brian from St. Joseph's Hospital to the Phoenix airport. I didn't realized that this expense was not included in the American Aerovac bill that I had paid. Anyway, when I saw that the ambulance claim had been approved and paid by Blue Shield I thought will why don't I have American Aerovac submit a claim for their service. I called American Aerovac and asked them to submit a claim. After waiting several weeks and resubmitting the claim 6 times Blue Shield finally made a determination that they were denying the claim because:

    "Based on the documentation provided, the medical need for this was not established"

    The documentation that I submitted was a letter from the doctor at St. Joseph's in Phoenix that says an air ambulance is the only acceptable way to transport Brian to Atlanta from Phoenix, the medical log from American Aerovac and the Blue Shield claim form. Brian's case worker at the Shepherd Center is now going to help me justify why the air ambulance was absolutely necessary. She said that she's going to submit a short but powerful letter that shows that an air ambulance was necessary and cost effective. Brian's doctor at the Shepherd Center has also agreed to submit a letter as the receiving doctor that says the air ambulance was the only medically acceptable method of transport.
    I think we're going to get reimbursed for the transportation because the reason for the denial is just wrong. I don't think that denying the claim based on not being medically necessary is defensible. I would have preferred that the claim had been paid but I was pleased when the claim was denied for not being medically necessary. I believe we can show that the air ambulance was necessary.

    Roger
    Roger,
    We flew our son from his first hospital that was in Minneapolis after his accident down to Texas to TIRR for rehab and had to pay for the air ambulance also. Blue Cross paid for the ambulances to the airports and then again to TIRR. At $11,000, it would have been great if BCBS would have thunk it necessary to transfer him 1,000 miles but didnt BC suggest that flying him all the way across the country was not necessary and that there were just as good rehab facilities where you are now?? I dont think I can go back 4 years anymore, but good luck with your endeavors.

  4. #84
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    Quote Originally Posted by Jesse's Mom
    Roger,
    We flew our son from his first hospital that was in Minneapolis after his accident down to Texas to TIRR for rehab and had to pay for the air ambulance also. Blue Cross paid for the ambulances to the airports and then again to TIRR. At $11,000, it would have been great if BCBS would have thunk it necessary to transfer him 1,000 miles but didnt BC suggest that flying him all the way across the country was not necessary and that there were just as good rehab facilities where you are now?? I dont think I can go back 4 years anymore, but good luck with your endeavors.

    Jesse's Mom

    When Blue Shield denied the transportation claim it wasn't because that there was rehab facilities available in Phoenix it was because:

    "Based on the documentation provided, the medical need for this was not established"

    I have a letter from Blue Shield authorizing treatment at the Shepherd Center in Atlanta once Blue Shield authorized medical treatment at Shepherd Center the medically necessary transportation from one hospital to another is covered by the Blue Shield PPO policy. That's what the Blue Shield Evidence of Coverage says.

    Roger

  5. #85
    Good luck Roger! It sure seems like they should cover it - and you've done your homework. Gene and I are pulling for you! We sure hope Brian is doing well. It was a pleasure to meet you at Shepherd! Take care!
    -Joanie

  6. #86
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    The transportation claim is being reviewed by a Blue Shield of California grievance coordinator. He has until July 6 to complete his review. Last week the case worker from Shepherd Center wrote a powerful letter justifying why Brian had to be transported by air ambulance to Atlanta from Phoenix. The argument that we're putting forth is: once Blue Shield authorized treatment at the Shepherd Center then the transportation from one hospital to another is a benefit provided in the Blue Shield PPO policy. The only issue Blue Shield can argue about is was an air ambulance the appropriate method of transport. I have letters from the attending physician in Phoenix and the receiving physician in Atlanta that say air ambulance was the only possible method of transport because of Brian's medical condition. I also have a quote from a ground ambulance for $28,300 for transport from Phoenix to Atlanta. The air ambulance cost $16,900 and besides Brian was not medically capable of riding in a ground ambulance for four days. If anyone has any suggestions on how I can better argue this claim let me know.

    Roger

  7. #87
    Roger

    If this insur is thru your company then check with them and see if they are a self funded group. If they are they make the rules and can override Blue Cross Ca ruling on paying for the air ambulance as Blue Cross is just the 3rd party adminstrator. It is possible that your group has a person that can assist you with this.
    Need to be careful also because most insurance companies have a limit as to the number of times you can appeal a decision. Make sure the denial you rec'd is from and MD and not just a nurse. I work for Blue Cross Blue Shield also and have done alot of work with Medical Review, and there are alot of times that only an RN denies the appeal and no MD is involved.
    You have the right to ask who the doctor was that reviewed the appeal.

  8. #88
    Bluecross, after much going back and forth, picked up my 35k cross country joyride. There were "official" no/case-closed at every turn. Persistance and ultimately a great case worker and doctor's order tipped the scale.

  9. #89
    Quote Originally Posted by Roger

    Will spasms diminish naturally so that he can be taken off Baclofen?
    Is there another drug that can be taken orally that could be used instead of Baclofen?

    Thanks

    Roger
    FWIW, I had terrible spasms that are decreasing by the day. I went from 100mg of bac (over max dose) and have whittled it down to 40mg-50mg. As Sci-nurse stated exercise, standing, stretching, activity are crucial.

  10. #90
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    Quote Originally Posted by alpentalic
    FWIW, I had terrible spasms that are decreasing by the day. I went from 100mg of bac (over max dose) and have whittled it down to 40mg-50mg. As Sci-nurse stated exercise, standing, stretching, activity are crucial.

    Currently Brian is on 60 mg/day of Baclofen. I've been talking to people about Project Walk. Project Walk considers spasms to be a good thing and use the spasms as part of their activity based therapy. Have you heard about that?

    Roger

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