"This is a request for a motorized wheelchair for a 3 year old child with cerebral palsy, failure to thrive, chronic lung disease, and hearing impairment. She has very low muscle tone in the neck and trunk and increased tone in her extremities. She has had 3 single trials in three different wheelchairs and proved she is successful in driving and demonstrated understanding of tilting herself and using controls. A motorized wheelchair cannot be approved as medically necessary per health plan policy guidelines, as there is no documentation that "the child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a two month trial rental period, AND as a result of the two-month trial there must be evidence that the use of the motorized wheelchair has enhanced the child's overall development including such things as cognitive abilities, directionality, spatial perception, and social skills such as independence and self-concept."
The list of expletives that come to mind after reading this are not appropriate for the blog. I can think of a whole list of "not medically necessary" things that they can shove up their collective...wait, I was trying not to use inappropriate language wasn't I?
I had heard through the equipment supplier, that the claim had been denied by our insurance company because they wanted us to do a two-month in home trial, and the lucky thing is that we actually DID do an in-home trial. This really was LUCKY because we had no idea the insurance would come back with this, and we only got the loaner chair through a twist of fate and the kindness of a few people we were working with. The claim has been resubmitted with the two-month trial information, so we'll see what happens.
Talking to the nice person from wheelchair seating, and seeing the denial in black in white from the insurance company, have proved to be two very different experiences. I guess it's just hard for me to see this beautiful child...
reduced to a number and a laundry list of impairments. Failure to thrive? That all depends on how you define THRIVE!