The Fight for Survival – Health Insurance Battle for Medically Necessary Wheelchair Seat Elevator – Final Decision

Over the last several months I’ve engaged in a head-to-head battle with my insurance company, Blue Cross and Blue Shield of North Carolina (BCBS), for a critical function on my power wheelchair called the seat elevator.  The seat elevator was deemed not medically necessary by my insurance company and after multiple appeals I was sent a final denial letter by BCBS. 

Unfortunately, Medicare and Medicaid, who often pave the way for private insurance company precedent decisions, deem much needed durable medical equipment such as shower chairs, seat elevators, standing wheelchairs, exercise equipment, etc. not medically necessary.  This status is very much a testament to our broken healthcare system in this country with respect to a “deny, deny, deny” policy.  There are tens of thousands of disabled folks in this country who are left behind because they don’t know how to navigate the inner workings of the insurance appeals world and the external review process outside of the system.

Last week I wrote an article outlining the various steps I have taken over the previous several months in fighting with BCBS over approving my seat elevator for a power wheelchair in regards to the process I have been through, why the seat elevator is medically necessary in my situation, tips and tricks for others, and my overall strategy (https://pushliving.com/the-fight-for-survival-health-insurance-battle-tactics-for-medically-necessary-services-part-2/.)  I was in the process of pursuing an external review with the North Carolina Department of Insurance to overturn BCBS’s final denial of my seat elevator.  Every state has its own Department of Insurance who sends your external review to an independent review board.

The trick is making your insurance company deem whatever piece of equipment you are after to be “medically necessary.” Despite over 70 pages of documents sent by my general practitioner, physical therapist, durable medical supplier, and letters were written by me- BCBS still did not seem to agree with my medical professional’s opinion of what “medically necessary” meant. 

I’ve been through the appeals process many times over the last ten years of being injured, but this time was different.  I went a step above and beyond to reach out to local news stations, wrote letters to the CEO BCBS NC, and had several folks working on the internal side.  I’m not sure which avenue yielded this welcome and frustrating result, but here’s what happened:

FINAL DECISION

Last week, a representative from the Divisional Compliance Appeals Department of BCBS personally called me to inform me that they had overturned their own final denial. 

What?  Exactly what I was thinking …

What changed?  The external review Board had not even met yet.  I strongly suspect it was Diane Wilson, an investigative reporter at ABC 11 News, who came to interview me and sent all of my files to her internal BCBS contact.  I will never know for sure, but media attention on this issue is likely not the kind of publicity BCBS is looking for.

When I received the call I was elated and infuriated at the same time.  Why the hell do I have to fight so hard when I pay nearly $13,000 a year for private health insurance to receive medically necessary equipment?  What about all of those folks who don’t have the energy, time, the know-how, or the support system to push as far or as hard as I have?

While I do respect the fact that we are so much more fortunate than so many other disabled folks in Third World countries, if we’re going to pay this amount of money in this country for our health insurance – we have to demand better – we have to do better.

 We have a shockingly opaque healthcare system where insurance companies aren’t doctors, so why are we letting them practice medicine?

A DIRECT CONTRADICTION

When I was applying for a power wheelchair with all of my medical professionals I was denied the seat elevator function.  My doctors and physical therapists then went through the appeals process and were denied for the first time.  On the second appeal, I got involved.  We sent further documentation to the BCBS appeals team to no avail.  The response I received several weeks ago was this:

“Seat elevators for manually and power operated wheelchairs are considered not medically necessary.  These items are considered a “convenience” and not medically necessary in the sense that they do not serve a specific therapeutic purpose, even though they may contribute to a patient’s independence or ability to assist caretakers in transfers, repositioning, or other aspects of movement during the performance of assisted daily living activities.”

Clinical Rationale:

“A BCBS NC Plan Director, in coordination with an outside doctor who is certified in the area of physical medicine and rehabilitation, has reviewed all available documentation.  The BCBS NC Plan Director stated in pertinent part, “… Uphold denial of coverage of a power seat elevator system per external review.  Based on an additional medical doctor expert Board Certified in Physical Medicine, the request for coverage of a power seat elevator system is not approved.  In this case, although a seat elevator will provide the ability for you to complete activities of daily living, it is not a covered medical equipment.  Therefore, the request is denied based on your medical policy.”

If you critically read the language, they consider a seat elevator a convenience even though it contributes to our independence?  Excuse my language, but what the hell?

That in and of itself is a contradiction.  It doesn’t make logical sense.  If many of these insurance companies paid for these medically necessary pieces of equipment, it would prevent many of us from trips to the emergency room; long-term stays in the hospital from pressure sores, infections, etc.  It costs them more money on the backend than if they would just pony up on the front end.

I digress …

In no uncertain language, BCBS told me my only course of action was to submit an external review with the North Carolina Department of Insurance.  I called multiple times and was told I had exhausted all my internal appeals.  The decision was final!

Was it Really?

Several days after Diane Wilson from ABC 11 news sent all of my paperwork to her internal contacts at BCBS in order to get a comment, I miraculously received a phone call from BCBS letting me know my seat was now approved.  Miraculously?  I think not Ladies & Gents ….

This was the official response to Diane Wilson from BCBS:

“BCBS NC follows a robust review process, in which all appeals are carefully considered.  BCBS NC always strives to do what’s best for our members, and we thank Ms. Ingersoll for the opportunity to serve her.”

I, in turn, received the following written response from BCBS a week later:

“Dear Ms. Ingersoll: I am writing in response to your request for coverage of a power seat elevation system.  Your request has been approved.  Benefits will be provided based on your coverage and eligibility at the time the services are received.  This administrative decision is based on the individual merits of the specific case.  This approval should not be considered a precedent for future or similar services …“

I had to stop several times to re-read the decision for my final denial by BCBS and then my approval.  The only thing that changed to reverse this decision is I became a royal pain in the ass. 

Honestly, it’s not as if I devised additional reasons why the seat elevator was medically necessary.  I just decided to push the envelope because I know that most folks don’t take the fight farther than several levels of internal appeals.  Once many receive a final denial from their insurance company, they give up.  Don’t misunderstand me, they don’t give up because they want to, but they’re not quite sure what to do or don’t have the fight in them, etc. 

I spoke with dozens and dozens of fellow wheelchair users, and they all told me the same thing; they admire the way I fight, but they don’t have the time, effort, ability, or energy to deal with these monstrous insurance companies because they are just trying to survive on a daily basis.

WHAT’S NEXT?

A lot!

I’m only getting warmed up.  I’m in a war.  I may have won this battle, but I have many more battles to win.  I need to create a sound strategy, align myself with a coalition of really smart people in the spinal cord injury world who have been fighting these battles for decades.  I am presently working on connecting myself with these individuals on a daily basis.  This war is going to become a full-time job for me.

Do I want to do this?  Not really, but I just about had enough, and I am a huge advocate in fighting for those who cannot advocate for themselves. 

I never fully grasped or understood how certain people in life were so driven with a singular focus.  It’s a shame that something outrageous often has to happen for us to rally the troops to take a stand.  However, that’s life, and I feel as though I have the ability to do that for so many others, whether it’s on a personal level of helping them with an individual appeal or fighting on the national front.

Next step, I’m going after a shower chair.  If you can believe it, most insurance companies do not believe a fully equipped shower chair is medically necessary.  Another article for another time, but I need to be able to appeal multiple decisions before going for the big kahuna ask of a lifetime.

My ultimate mission is to have my health insurance company pay for caregiving services.  I’m not talking about having several hours a week from an agency with undertrained caregivers, but having them allow our loved ones or caregivers of our choice to take care of us, and pay for it.

I am a C6 quadriplegic paralyzed from the chest down, and I do need full-time care.  Under my insurance plan, it says I am only allowed 60 hours a year, yes you read correctly, of home health aide from an approved healthcare agency.  Presently, I pay out-of-pocket for private caregiving.  I have to, and it eats up about 60% of my budget every year.  I respect most people don’t have the ability to even do this.

This is a huge ask and may take several years, but you have to start somewhere.  Unfortunately, I’m not quite sure about the state of Obama Care moving forward in our country.  This will be a major factor in how hard I’m able to fight or if I can even afford health insurance if they take away a very particular line item within health insurance company policies of being able to discriminate against pre-existing conditions with respect to premiums and out-of-pocket costs as they once did.

I am the captain of my own ship and preparing for a long voyage. It’s going to take endurance and stamina to circumnavigate the treacherous waters ahead of me, and I can only imagine the obstacles that lie ahead. Still, I have a great crew, top-notch equipment, excellent navigational maps, good old-fashioned dark humor to get me through it.  Stay tuned!

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