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Getting Elevation Approved on a power wheelchair

We just had Jonathan's assessment for his power wheelchair. One of the things he needs is the elevated height. He needs this to be able to adjust his height to reach the lab tables for his classes. His major is biology, so he has a lot of lab work in Biology and Chemistry. Any ideas or help on how others got it approved via insurance and medicare would be appreciated. We are NY state. Thanks for your input.

Christine and Jon Piacentino

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Permalink Reply by Jennifer Shumsky on December 3, 2011 at 1:58pm

I can't help in how to necessarily get it approved, but I do work as an appeals nurse for a medicare insurance group and I have sent many appeals off to Maximus (Medicare's independant review entity) for power chairs with the elevated height and I have NEVER seen Medicare approve it. It is statutorily not covered, no way, no how. It is considered a convienence item (so are full electric hospital beds). So whatever you can do to make sure your insurance company understands that they cannot follow Medicare policy when reviewing this for Jonathan is paramount. I think just having a letter from the ordering practitioner explaining the need for the elevating seat and how it is importat to his ongoing self care/independance (ability to complete college and support himself with a job some day) and how it is medically necessary as if it was not approved he would be forced to be in unsafe positions in the classroom that could lead to falling out of his chair (we all know how dangerous that is!), increased fatigue from not being elevated correctly (from poor posture/breathing) etc... If it is denied the first time, then appeal and appeal again.

Good luck! Hope this helps.

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Permalink Reply by Christine Piacentino on December 3, 2011 at 3:11pm

Thank you Jennifer, your insight is very helpful. We are pretty good at fighting for these we need. And are well aware that we will probably need to appeal this a few times.

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Permalink Reply by Michelle Scaglione on December 3, 2011 at 5:41pm

When Johnnys was approved we informed them he needed it to be independent in reaching for light switches, cooking, washing dishes, table heights etc. He was approved through medicaid 7 years ago so I dont know if this will work now. He has a great PT who has gotten him approved.

Michelle

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Permalink Reply by Katherine M. Reynoldson on December 3, 2011 at 8:06pm

Hi Christine,

Hope everyone is well and Jonathon is enjoying college. Another route to consider is MDA's equipment allowance. I believe that they will assist with non-covered (by insurance) durable medical equip. needs. There is an annual cap to the amount and it seems to change frequently but I would have the vendor contact them to see what they will help with. If you don't get anywhere let me know and I have a few other potential ideas.

Best,

Katherine

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Permalink Reply by Christine Piacentino on December 3, 2011 at 8:34pm

Thanks Michelle, these are great ideas to include in his justification letter. I appreciate the input.

Michelle Scaglione said:

When Johnnys was approved we informed them he needed it to be independent in reaching for light switches, cooking, washing dishes, table heights etc. He was approved through medicaid 7 years ago so I dont know if this will work now. He has a great PT who has gotten him approved.

Michelle

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Permalink Reply by Christine Piacentino on December 3, 2011 at 8:40pm

Hi Katherine, Yes, we are well and Jonathan is enjoying college. He is struggling with English but seems to be enjoying his Biology and Chemistry classes. He is taking 14 credits a semester and it seems to be ok. Unfortunatly the MDA in Rochester has stopped the equipment allowance with money. What they have chosen instead is to expand their loaner closet. Jonathan is using a power chair from the loaner closet which is stored at school. They will allow you to use the loaner for as long as you needed and will pay for repairs on it. But they no longer provide money for purchases of new equipment. Thanks for the input. I will let you know how it goes. I think that we may have to go through the appeal process to get if fully covered.
Katherine M. Reynoldson said:

Hi Christine,

Hope everyone is well and Jonathon is enjoying college. Another route to consider is MDA's equipment allowance. I believe that they will assist with non-covered (by insurance) durable medical equip. needs. There is an annual cap to the amount and it seems to change frequently but I would have the vendor contact them to see what they will help with. If you don't get anywhere let me know and I have a few other potential ideas.

Best,

Katherine