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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