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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