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

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.

Have you had rotten customer service before? Of course. We all face this nearly everyday at almost every place we do business at, or seen as a patient at. And somehow we only whine most about all of that to each other, and tend to not mention as often the times we find excellent service.

Well a local company to me that sells Durable Medical Equipment called Monroe Wheelchair got off onto the wrong foot with my wife am I. We had gone in person to find replacements for my handrims on a donated standard style wheelchair.

Here is my letter I sent to the owners of that company:

Dear Owner(s), and Dave, of Monroe Wheelchair,

I write to you today to both mention a complaint, and then a kind word or two about Dave Hebert. And I tried to keep this as short as possible, it is two letters in one really. One page each.

My wife’s and my first experience with Monroe Wheelchair was horrid at best. Several months back now, we enter the store in a donated wheelchair to me. A basic standard issue one. Nothing major to it.

The first person we speak to explains you do not sell just handrims. OK, so how about buying some wheels with better handrims than I had. This same person told us between $50.00 to $100.00 for a basic set of wheels with handrims. OK, we had no way to know the prices of these things. And this was all new to us. And this first person was pleasant enough to us.

This first person gets the manager at the time who comes over and proceeds to share with us that you only sell wheels for $500.00 and up. My wife and I then asked OK, what about buying a wheelchair? Now never once did this manager ever take into account my personal needs as a possible first time customer, and a member of the community.

Of those two chairs he would show me nothing that met my needs in any respect. He was very curt, and rude with us. Accused us of having a stolen wheelchair. Would not allow me to explain how I came to have this chair. And talked over us.

I saw that another folding wheelchair is next to the standard ones. I ask about it, and this manager laughs saying that would cost many thousands of dollars. Frankly as far as he knew I have money to spend on my needs or I have a script on hand to get a wheelchair my insurance would cover. He never once explained it to us, showed it to us. Or allowed me to even sit in it for fit. He in effect sent us packing. That is OK, I sent an email to the manufacturer of that other wheelchair explained what took place.

My wife and I made a promise to never use Monroe Wheelchair for anything again. I will not accept that form of service from anyone at all for non health or medical equipment needs. I for sure will not now.

Might I suggest this not happen again. Thank you.

And now for those kind words.

You have a young man David Hebert, Rehab Technology Specialist.

I work for Strong Orthopedics and it would be through them I got Dave’s name as being the very best in all of Upstate Western NY at fitting people in wheelchairs. If his name did not come from them as such I would had found someone else. And it was not an easy choice to trust that Dave would change my feelings about Monroe Wheelchair.

Well first off Dave’s level of customer service lives up to the ads I hear, and the text I read online about Monroe Wheelchair. His service is not just good or very good. It passes all of that and is in the realm of EXCELLENT. Something that is lost today in most all companies, and one I thought lost at Monroe Wheelchair.

I have never sent someone a compliment letter before.

Now you may be asking yourself what can be done to show that Monroe Wheelchair does want lifetime customers, who will tell others to also use them?

Well please do not allow such horrid customer service to be accepted as the norm. That is first thing you can do.

Second and lastly Dave did not only provide excellent customer service to me. He changed my life for the better. That is huge, and the only reason I took the time to write this letter.

Having many of these kinds of letters myself, I know that the letter is often the reward in its own right. And sometimes the boss will step up and give a pen with the company logo on it. Well Dave Hebert CHANGED my life to the better, and I now ask that Monroe Wheelchair’s owners step up and do more than a simple pat on the back for Dave. And also this will provide real good incentive to prevent less than excellent service from happening again. Sorry bad days are to be left at home with the excuses why it happened.

What would show Dave my thanks while showing me that Monroe Wheelchair does care about the customer. And resolve the above horrid issue of less than poor customer service as well.

Allow Dave Hebert his choice of any TiLite model wheelchair in any configuration he wants as his reward for doing such an excellent job. He was the man that showed me what I heard in the ads for Monroe Wheelchair. And he has won me as a lifelong customer, and insured I will be telling many others about your company.

It is of course up to you on how you choose reward Dave, and handle this customer issue.
You can write the reward chair off in your taxes and not take a big hit on the bottom line at all. And gain one very happy lifetime customer, that will add to the bottom line. Dave deserves more than a simple way to go man, and me just saying thank you, does not come close to how much this man has helped me.

Thank you for your time today,
Wheelman

So I sent this off the other day.

So will the owners really award Dave his choice of a wheelchair as I requested? Only time will tell.

What I wanted to highlight though was that yes a bad experience was had here. And now I request a way to resolve it, offer good incentive to prevent it from happening in the future. And even though this took me many days to type up, and deal with the pain I do. I took the time to write it all, and send it.

I think it is time we as people stop with the mediocre, and strive for excellence.

For the owner or that manager of Monroe Wheelchair may one day need my services. If my job is such that life depends on my having a good day or bad one… Karma has this odd way to even things out in the end. And only after learning the hard way myself that, I no longer think of Karma as something my mom made up to scare me.

Thanks for the time spent reading my reviewtoday,
Wheelman