Kendall,
Sending you my copy of the justifications for wheelchair modifications.  Of
course, you would modify it for your needs.  Hope it gets to you, it's a
really large file.

Beth t the OT 

> -----Original Message-----
> From: Cerebral Palsy List [mailto:[log in to unmask]] 
> On Behalf Of Kendall D. Corbett
> Sent: Thursday, July 23, 2009 4:28 PM
> To: [log in to unmask]
> Subject: Re: Still Fighting for New Wheelchair
> 
> Beth,
> 
> Not yet; the controlling paragraphs in the denial letter read:
> 
> "According to Health Plan Policy, the Levo C3 Standing Power 
> wheelchair and Standing Seat System is not considered 
> medically necessary.It is noted that the patient's last 
> wheelchair was purchased in 2003.
> 
> According to your plan, the definition of medical necessity 
> includes the
> following: Health care services and supplies, that a 
> physician, exercising prudent clinical judgement, provides to 
> a member for the purpose of preventing, evaluating, 
> diagnosing or treating an Illness or Injury or its syptoms 
> that are not more costly than an alternative service or 
> sequence of services; not primarily for the convenience, 
> psychological support education or vocational training of the 
> Member, physician or other health care provider; and are 
> clinically appropriate, in terms of type, frequency, level, 
> extent, site and duration, and considered effective for the 
> Member's illness, injury or disease."
> 
> The next paragraph says that I can request, in writing, "a 
> written explanation of the criteria and/or clinical judgement 
> used to evaluate the request," which I have done, but have 
> not received yet.
> 
> In the above paragraph, the part about a physician exercising 
> prudent clinical judgement has been met. "For the purpose of 
> treating, evaluating..." has been met. "Not more costly" has 
> been met, unless several of the features that my doctor feels 
> are clinically indicated are deleted. "Not primarily for the 
> convenience..." has been met. "are clinically appropriate..." 
> has been met.
> 
> 
> If you have the evaluation form in electronic format, I'd 
> love to see it!
> 
> Kendall
> 
> 
> On Jul 23, 2009 1:42pm, ehthiers <[log in to unmask]> wrote:
> > Kendall,
> 
> 
> > I have a very extensive wheelchair evaluation form that I got from a
> 
> 
> > wheelchair dealer for Medicaid. It goes through medical and 
> functional
> 
> 
> > reasons for each and every piece of equipment. It ends up 
> being close 
> > to 20
> 
> 
> > pages long. ROM, strength, etc needs are spoken of. Also, 
> for an adult
> 
> 
> > cardiovascular, prevention of decrease function, improving 
> and maintaining
> 
> 
> > ROM and strength (all the way through the body), respiratory reasons
> 
> 
> > (opening of trunk, etc) along with independence, decreased need for
> 
> 
> > assistance and improved ability to move through 
> environment, configuration
> 
> 
> > of house and work spaces and need to be able to go up and 
> down stairs (how
> 
> 
> > many in immediate environment), improve self care skills 
> and ADL and work
> 
> 
> > load, decreased decubiti and pain management, etc.
> 
> 
> 
> 
> 
> > Are they giving you an exact reason for denial?
> 
> 
> 
> 
> 
> > Beth t the ot
> 
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