Magazine article The Exceptional Parent

Appealing a Denied Claim

Magazine article The Exceptional Parent

Appealing a Denied Claim

Article excerpt

Q My nine-year-old son has Duchenne muscular dystrophy. He has immediate need of a new power wheelchair. His present chair is too small and is aggravating the contractures of his leg muscles (shortening of muscles resulting in stiffness).

I have been verbally denied coverage for the wheelchair based on the first round of letters we have sent to the insurer. We are now appealing with letters from three doctors. One letter is cosigned by a physical therapist. If you can help, I would appreciate it.

A Unless your insurance policy specifically excludes or limits coverage for durable medical equipment, or equipment for children with specific disabilities, a power wheelchair is usually considered a covered item.

However, insurance policies provide coverage only for equipment that is "medically necessary." Supporting documentation, such as a doctor's letter, is often required to demonstrate medical need for the equipment.

The number of letters sent with a claim appeal is not as important as their content. First, the letters must be signed by a physician. Second, although requirements differ from insurance company to insurance company, the letters must include specific information about the child's medical condition.

The letters you include with your claim appeal need to explain why your son needs a wheelchair and why he cannot use a manual wheelchair. That information may already be on file with the insurance company as a result of prior claims, but it should be noted again. Since the claim is for a replacement wheelchair, the letters should also explain why your son's current wheelchair no longer meets his medical needs. If your son's need for a new chair is related primarily to his height and weight, the letters should include information about his size.

It is important to talk with your son's physical therapist and a medical equipment professional (who also may be called a 'rehabilitation and technology supplier" or "dealer," since he or she sells equipment). These professionals can recommend the specific power wheelchair most appropriate for your son. They can also describe the accessories--specialized switches or controls, special seats and/or cushions, special arm or leg rests--that your son may need with the wheelchair. These accessories, which can be quite expensive, may be covered by the insurance policy if purchased with the wheelchair, but may not be covered if purchased later, as separate items.

By necessity, medical equipment suppliers have developed considerable expertise on preparing written documentation for specific local health insurance companies and are likely to have specific suggestions for how such requests should be phrased. …

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