Freedom: No Longer Medically Necessary

DJ Stemmler delivers a timely warning from the front lines of rehabilitation

Dear Disability Community,

Beware! You may not be able to get the devices you think you can from insurance companies! For the last several months I have been appalled at the current trend exhibited by the insurance companies I have dealt with on a daily basis in trying to obtain wheelchairs and assistive technology for people through our clinic.

I use a wheelchair and numerous other assistive technology devices. I also have worked in human services all of my adult life, for the most part in rehabilitation. Normally we have a pretty good success rate in winning reimbursement for equipment through insurance companies even if in some cases we have to file appeals. And although I am most familiar with funding criteria for wheelchairs, lately I have seen a complete turnabout and find some of the most recent denials downright negligent, abusive—health insurance practice.

In a recent denial from Highmark Blue Cross and Blue Shield, we requested power accessories for a client with ALS and cancer who is also vent dependent. They were flatly denied. We expedited the appeal by having our physician call the appeals line and we were again denied. The power base was approved but the power accessories such as tilt, elevating leg rests and elevating seat lift were not approved because “he will have constant attendant care and they are not medically indicated.”

In another case of denial from Highmark Blue Cross Blue Shield, a 43 year-old woman with MS who uses a power wheelchair, works five days a week and lives alone was denied similar power options “because the manual versions are adequate as the patient will continue to require more attendant care from family members who can manually adjust the wheelchair for the patient.” In one denial letter there was even a suggestion that the “patient” could ask a co-worker to adjust their position so therefore the need to do it independently was “not medically necessary.”

Wheelchairs, scooters and manual wheelchairs are meant to decrease a person’s dependency on others, not increase it. The features that allow someone to independently adjust the position they are sitting in through weight shifting, elevating their legs or reclining can be literally life-saving. These features can prevent skin breakdown, decrease edema and even allow a person to breathe better.

Living with a disability can be extremely difficult, but living in pain because of someone else’s stupidity and ignorance is inhumane and unnecessary. These power accessories aren’t toys and aren’t recommended as part of a wheelchair manufacturer-prescriber conspiracy to defraud insurance companies.

Our clinic sells no devices and represents no specific wheelchair manufacturer. There are no perks associated with recommending the power options. We don’t get kickbacks or commission. Without the ability to independently change positions, people are in pain. Denials like these are not only resulting in people not getting the equipment they need, but also inflicting pain on an already vulnerable and sometimes pain-ridden population.

I don’t have my degree in common sense but I am confused by these recent denials. The insurance company’s role is not to pass a value-laden judgment, implying that a subscriber with attendant care services needs to be less well-equipped for independence than someone who doesn’t have attendant care. People who get attendant care are often more disabled than those who don’t.

Usually the most severely disabled or chronically ill people need these power seat functions. Aren’t denials like these providing a mechanism for insurance companies to deny services to people who are more severely disabled—the very population they are supposed to support?

Or maybe they are a tool to make sure that only very determined people get what they need. People with progressive and terminal illnesses often don’t have the energy or time to fight an appeal and will often settle for less. Could these denials be delay mechanisms used by insurance companies to have the appeal process outlive the intended recipient?

It has been an honor up until now to work in the rehabilitation profession. But because I can’t rationalize, justify or understand this type of discrimination, today I find it hard to come to work each day and know that some of my clients won’t ever get their wheelchairs because the appeal process will kill them off before their disabling condition does.

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