A Reviewers Blog

Aetna

4-30-08

Wheelman

Subject: Final Appeal Decision

Sear Mr. Wheelman:

This letter is in response to the appeal request we received on April 30, 2008. This appeal is regarding the denied predetermination request for the TiLite ZRa wheelchair and accessories supplied by Monroe Wheelchair.

A medical director, board certified in internal medicine and geriatrics, who was not involved in the original decision, participated in the review of this appeal. We reviewed all available information including:
* your correspondence,
* clinical documentation submitted,
* and Aetna Clinical Policy Bulletin Number 271.

Our Decision
Based on our review of the above information, we are reversing our previous benefit decision and will now allow benefits for this TiLite wheelchair and accessories.

Upon review of the submitted clinical documentation and the related clinical policy bulletin on wheelchairs, the prior determination is overturned. Coverage will be allowed for the requested ultra light wheelchair, special wheels/tires, and other accessories. With the diagnosis of sacroiliac dysfunction and your unique clinical situation, this wheelchair appears to provide the most benefit to support activities of daily living with the least amount of discomfort and with improved mobility.

>>My original goal was to acquire myself independence inside my home. I did not expect to also find the system as broken as I did…

Source

Aetna I will show the public about your un-ethical ways…

Aetna you see uses the Medicare guidelines as its method to ISOLATE DISABLED PEOPLE and elders as well.

>>Supporting article actual can fit for any medical insurance company using this model, above is my comments, and frustration.<<

Older adults and people with physical disabilities can get Medicare coverage for mobility devices, like wheelchairs, walkers, and scooters, which are necessary for use in their homes.

However they cannot get coverage for mobility devices that are solely for functioning outside their home. ((My observation: Or DME to enable both in one piece of equipment.))

Since the institution of Medicare’s coverage standards for mobility devices, and other kinds of durable medical equipment, nearly four decades ago, advances have been made in three critical areas: (1) improvements in design of mobility devices that allow people to participate more fully in their communities; widespread societal recognition that with appropriate accommodations many limitations on functioning can and should be lifted; and (2) recent court decisions requiring that individuals with disabilities be provided with the necessary supports to live as independently as possible in their communities.

The current interpretation of Medicare’s coverage standards for mobility devices does not reflect these advances. The Centers for Medicare and Medicaid Services’ (CMS) interpretation of Medicare’s coverage standard prevents people from getting needed medical equipment to function within their communities. ((My observation: this part of the population if covered private health insurance, are also forced into isolation because of these outdated guides)).

By contemporary medical and legal standards, the [CMS's] interpretation is unreasonable and quite likely unlawful. The Medicare statute neither specifies that durable medical equipment is exclusively for use in the patient’s home nor bars consideration of an equipment’s use outside the home.

There is no indication of Congressional intent to support this limitation of coverage. CMS has both the authority and the responsibility to interpret the Medicare statute so as to be consistent with historical developments in law, technology and social mores.

United States Supreme Court precedent holds that agencies are “charged with the administration of [a] statute in light of everyday realities.” Everyday realities have changed since Medicare was launched in 1965.

Laws such as the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and the Ticket to Work and Work Improvements Incentives Act of 1999 reflect a broad, bipartisan commitment to increasing community integration of people with disabilities.

This commitment is evident in judicial decisions, including Olmstead v. L.C. ex rel. Zimring, and executive orders, such as President George W. Bush’s New Freedom Initiative, a set of proposals to promote opportunities for Americans with disabilities to learn and develop skills, engage in productive work, make choices about their daily lives, and participate fully in their communities.

Developing political and legal standards are consistent with medical opinion: the costs of isolation for people with disabilities can include poorer health outcomes and higher systematic health costs.

Also, scientific evidence indicates that people who get inappropriate mobility devices given their needs develop secondary medical conditions. In light of technological advances that today make appropriate equipment available and community integration possible, CMS has a responsibility to update its interpretation of the Medicare statute.

While CMS must rightly be concerned with costs associated with a more modern interpretation of Medicare’s coverage policy, other insurers have found that an appropriate standard has not led to an explosion in the provision of more expensive mobility devices.

Specifically, the brief recommends that the Centers for Medicare and Medicaid Services: (1) correct its Medicare coverage policy to cover medically appropriate mobility devices that help maintain or improve functioning for people in the environments they are likely to encounter in their daily routines (both inside and outside of the home), and (2) guard against unnecessary expenses for Medicare by incorporating mandatory equipment evaluations to ensure that people receive equipment that matches their needs.

While durable medical equipment encompasses a wide array of assistive devices, this brief will focus on wheeled mobility items, recognizing that this analysis will have varying applications to other durable medical equipment as well.

Source of information above:

http://www.medscape.com/medline/abstract/16447855

A general breakdown of the different levels of wheelchairs.

Standard Weight Wheelchairs

With weights starting at 35 pounds, a standard weight wheelchair is the perfect choice when you need a wheelchair that will be used less than 4 hours per day, but needs to be self-propelled. A full selection is available from the most basic models with fixed legrests and armrests to wheelchairs that have elevating legrests and removable armrests. There are also models with a “hemi” height option. This option allows you to lower the seat-to-floor height and remove the legrests so that the user can use their feet to help propel the chair. All standard weight wheelchairs fold for easy transport and storage. Consider a foam cushion for additional comfort.

STANDARD WHEELCHAIRS as well as LIGHTWEIGHT WHEELCHAIRS and
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIRS

These are mostly used in nursing homes, hospitals, departmental stores, airports etc. for temporary transportation of persons who need aid for mobility. These are NOT Dialy use fulltime wheelchairs.

Lightweight Wheelchairs - Also High Strength Lightweight Wheelchairs

With weights 30 lbs. and above, a lightweight wheelchair is a great choice when you need a wheelchair that will be used more frequently, when you need special options, or if your able to lift this weight range you will be set. The lightweight wheelchairs start with standard style models and move to somewhat more adjustable models. However, none of the models I could find online or in person offered some very important adjustments for a full time user of a wheelchair. The areas of adjustment for any of the 30 pound wheelchairs in the “class” of lightweight included verticle rear wheel height adjustment of an inch or two, armrest adjustemts, and maybe a tiltable back to the seat.

Ultra-lightweight Wheelchairs

With wheelchair weights as low as just under 10 pounds (rigid frame) and up with frames available in both rigid and folding models.The ultra-lightweight wheelchair is the best option for the full-time user. These wheelchairs offer areas of adjustment that can effect long term levels of comfort. These areas include CENTER of GRAVITY – This allows a user to adjust how much force it takes to push themselves.

Also important is how the use of this adjustment can greatly reduce shoulder injury over time,

and require even more medical attention that could be avoided.

The next area to adjust is Front Seat Height and also Rear seat height independent of the rear axle. This allows for better arm and hand placement over the wheels, but also for many users the comfort the adjust allows for long longer sitting. You can adjust the seat pan from flat to dump or lower front end, and or to bucket the seat for users like me who need that angle to sit in more comfort. Front wheel angle, this allows for even more front of seat/wheelchair adjustment and or to allow for fine tuning to better fit under desks, tables and such.

In effect the Dialy use or Ultra-Light wheelchair should just be renamed as the most ERGONOMIC wheelchair for a long term user. As the standard
class, and the Lighweight/High Strength Lightweight classes fail to offer these same levels of ergonomincs for the full time wheelchair user.

Standard Wheelchairs are the expected norm for most insurance claims. No need for any special evaluations or extra requirements.

Lightweight Wheelchairs not much different than Standard wheelchairs, insurance company’s require (at least Aetna doesn’t) very much effort on the end users part to get one of these. Maybe a OT mobility evaluation… But most likely not needed at all.

The Ultra-Light ( I call these the ERGONOMIC) Wheelchairs – These require the most effort to attain. In fact a denial and then an appeal, and maybe even then you still end up not being allowed this option. Will require an OT Mobility evaluation, and documents to support the need for this style of wheelchair.

Aetna I CURRENTLY OWN a High Strength Lightweight Wheelchair in the 30 plus pound range.
IT FAILS TO MEET MY NEEDS.

ERGONOMICS -

Ergonomics (or human factors) is the application of scientific information concerning objects, systems and environment for human use (definition adopted by the International Ergonomics Association in 2007). Ergonomics is commonly thought of as how companies design tasks and work areas to maximize the efficiency and quality of their employees’ work. However, ergonomics comes into everything which involves people. Work systems, sports and leisure, health and safety should all embody ergonomics principles if well designed.

It is the applied science of equipment design intended to maximize productivity by reducing operator fatigue and discomfort. The field is also called biotechnology, human engineering, and human factors engineering.

Ergonomic research is primarily performed by ergonomists who study human capabilities in relationship to their work demands. Information derived from ergonomists contributes to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people (IEA, 2000).

Applications

The more than twenty technical subgroups within the Human Factors and Ergonomics Society (HFES) indicate the range of applications for ergonomics. Human factors engineering continues to be successfully applied in the fields of aerospace, aging, health care, IT, product design, transportation, training, nuclear and virtual environments, among others. Kim Vicente, a University of Toronto Professor of Ergonomics, argues that the nuclear disaster in Chernobyl is attributable to plant designers not paying enough attention to human factors. “The operators were trained but the complexity of the reactor and the control panels nevertheless outstripped their ability to grasp what they were seeing [during the prelude to the disaster].”

Physical ergonomics is important in the medical field, particularly to those diagnosed with physiological ailments or disorders such as arthritis (both chronic and temporary) or carpal tunnel syndrome. Pressure that is insignificant or imperceptible to those unaffected by these disorders may be very painful, or render a device unusable, for those who are.

Many ergonomically designed products are also used or recommended to treat or prevent such disorders, and to treat pressure-related chronic pain.

Wheelman

Aetna – Review so far…

I have as many people do medical insurance, and everyone knows the nightmares with being in phone limbo… The never ending voice prompter asking you to say, press, or not do anything… As you hold for what seems days.

Well I recall having the Blue Choice insurance years ago now. I called I think twice and each time spent over 20 minutes in that frustrating phone hell, then after you did all that… Then your actual hold time started.

What most companies fail to grasp is that when people do not get another person, THIS IS THE SAME AS BEING ON HOLD. Even the self help options that you can use is nothing but being on hold. They can not answer a question, or look up another request… And often times what you end up needing is a live person anyway.

Well as of late the entire insurance industry has been getting hit hard with more awareness as to the kinds of things they really behind the scenes… This post IS NOT ABOUT THAT.

This post IS ABOUT the access to my insurance companies live customer service people and how they treat me on the phone.

Well the times me or my wife have had to call Aetna the automated system is AWESOME! Plain and simple. Really, you call you get I think three maybe four in total questions to be able to talk to a live person. Or PRESS ) (Zero) at anytime to bypass the automated system. And the auto process accepts voice and button input making it easy to use. Also the entire process is about the same as when you get a front desk person and ask to be connected to another person.

About one minute is the time it takes to get told you are now being connected to customer service… And each time we have called hold time is maybe two minutes or less. And the people on the phone have been rather nice.

Some have more personality right away, others seem to warm up after talking to you a little. In any event and so far no matter what I need to find out. The people at Aetna’s customer service do not rush you through the call, they listen to what you are saying. And are eager to help as best they can.

Now it might help that I know what they are doing on there end of things that I am more patient, and having dealt with my medical issue for as long as I have, I have learned that being angry at everyone, and going into my entire medical case with each person is NOT the best thing to do.

Each person I have talked to has been shocked that I am not yelling, not in a hurry to get things done, and am easy going with them on the line. They actually tell you that they are pulling up information as they talk to you. They will call your Dr’s office while you hold, so they can insure that correct information was sent to them as you expected it be. The customer service is not excellent, however it is, very good.

Dave if and when you read this Update if you find that Yahoo site send the kink to my email you have for me. Thanks.      > It has been updated Dave. Thanks for mentioning it to me.

http://www.monroewheelchair.com/index.html#MissionAndValues

OK, I want to update the review on Monroe Wheelchair – Karma I posted here
http://wheelman.wordpress.com/2007/12/14/monroe-wheelchair-karma/

I understand that the people at Monroe Wheelchair have in fact done something to insure that such poor treatment of anyone by the person who I dealt with, will not happen again.

To the owners and people in charge of Monroe Wheelchair, thank you.

Thanks to Dave Hebert, and Dave alone I have decided to become a life long customer of Monroe Wheelchair. Dave you see offers excellent and awesome customer service, and is a true asset to Monroe Wheelchair.

Dave’s level of customer service is not just OK, or Good. I expect good service at least from any company I deal with. Mediocre does not cut it for me at all.

The level of customer service Dave offers people in need of a first time wheelchair is beyond Very Good. It is easy to see and hear that Dave has deep passion for the people he helps. It is also easy to see he does not treat anyone like a number.

Now Dave is part sales person, as well as a wheelchair fitter. I have been in sales/retail for a large part of my life. Even when I had to switch over to medical office support, I found that I needed to keep on selling. Only thing now I was selling people in pain a warm smile, a kind word, and a reminder they are still human in this crazy rush, rush world of today. In effect I was selling the fact that Strong Hospital is staffed by people who care about people as human beings. Not just for the type of insurance they happen to carry.

So what Dave can do is up to him on how he goes about dealing with people he meets. All I can say is that what Dave has is not something anyone can teach him. It is built into who he is as a person. And it is very refreshing to meet someone who enjoys and loves what they do for a change.

I am so happy I gave Monroe Wheelchair a second chance by keeping my appointment with Dave with the OT for my mobility evaluation.

Knowing that the kind people of Monroe Wheelchair promptly took care of an important concern I had not just for myself, rather for other people as well. Has made me a huge fan of them now.

I recommend anyone looking for quality equipment,.people who know what they are doing, and want a fair price on medical equipment, check out…

http://www.monroewheelchair.com >> Please see The List of Excellence – 100% Wheelman Recommended Links over to the upper right of this page for the live link. And the link will open to a new tab or window.

From a bad to excellent experience all thanks to Dave. And for anyone wanting to know, I am not related to, do not work for, and am not paid anything in any way for my reviews here. I do not accept payment for a good review. Why? Well if you have a bad experience, it will be my blog you remember as the one who sent you.

No products had been offered in exchange also for a good review, or update post.

For those leaving comments, or wanting to. Please see the Read Me over to the upper right of this page.

Thank you for reading my review.
Wheelman

PS: Please see the List of Excellence page in the upper righthand corner of my page here. You will find Monroe Wheelchair as the first place listed on it.

PPS: I am now working on an award that I hope means more than any other given before. Why? My award is based 100% from a customer’s point of view. The end user of the service and products Monroe Wheelchair offers. I will be making a page devoted to winners of my one of a kind customer awarded awards.

I will be doing this for Products, Services, Blogs, Web-Sites, and such. The details of these awards will be included on the new page for them.