Old 12-18-2013, 06:33 PM #1 (permalink)
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Default Avoiding DME denials

We have become pros at avoiding denials of coverage for high-mobility DME (wheelchair, patient lift, hospital bed, slings, tilting shower chair, etc.). We have won all of our appeals for the equipment we need and now have high-level personal contacts with all DME decision-makers. Here are some tips to avoid DME hassles:

1) Appeal all denials. If your doctor prescribed it, it means you need it, so don't take no for an answer if you get a notice that coverage is denied. We have found that the drones who deny coverage are always overridden by sensible, caring people who handle appeals.

2) NEVER argue that you need equipment for outdoor use or for bathing. Even though you need equipment for outdoors or bathing, DO NOT talk about it with the DME people. The reason? (1) Most likely your coverage is limited to DME "for use in the home," meaning that even if you really need it outdoors, it just isn't covered. (2) There is a "hygiene exclusion" that DME people point to in order to deny bathing equipment like tilting shower chairs.

3) Instead, ALWAYS tell them the equipment is needed for assisting with TOILETING. There is no exclusion for this. All of your important, expensive DME can be obtained if you can show why you need it for toileting. Examples:
a) When coverage for the "elevator" functions on my wife's power wheelchair and hospital bed were denied, we were able to show that she needed these features to assist her in standing up to transfer to the toilet. These things were then covered.
b) When coverage for the rolling, tilting shower chair was denied, we were able to show that she needed a rolling, tilting COMMODE chair, which rolls over the toilet. It was then covered.
c) When DME wanted to give my wife a crappy sling that would not allow her to use the toilet while in the sling, we got coverage for a high-end Molift divided leg sling that allows transfers to and from the tilting commode chair without ever having to remove the sling to do her business.

4) Enlist the help of your own occupational therapist. The best OT will be the one at your ALS clinic. They will be happy to write letters supporting your need for the equipment. (Just make sure they understand not to say anything about using it outdoors or for bathing!) At every visit to your clinic, make a point of asking the OT to help you get the equipment you have been asking for.

5) Upon receiving a denial letter based on lack of medical necessity, ALWAYS demand to be told the scientific or clinical guidelines used to support the denial. This will send them into a tailspin, because there are no scientific or clinical guidelines regarding prescribing high-mobility DME to ALS patients. Medicare guidelines for DME are not directly relevant to ALS patients, because ALS was not considered when the guidelines were written. Anyone who looks into this will discover this is true, and they will not be able to comply with the law requiring them to provide the scientific or clinical guideline to support the denial. In short, if your doctor or OT says it's medically necessary, then it's medically necessary. Period.

6) Finally, get the phone numbers and emails of the decision makers who are in charge of the drones who write denial letters. You will never get anywhere with the drones, because it is their job to follow narrow procedures and NOT make decisions, and they want to be good at their job. Once you have gone over their heads and established a relationship with the directors and they know you have ALS and what that means, they will want to help you. It's human nature.

I'm sure we're not the only ones who have had to deal with ridiculous DME denials, so I hope this helps.
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Old 12-21-2013, 10:55 AM #2 (permalink)
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Default Re: Avoiding DME denials

Thanks for the info. My Medicare just kicked in and this helps me to be prepared.
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Old 12-22-2013, 10:36 AM #3 (permalink)
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Default Re: Avoiding DME denials

Great set of tips. Thanks so much for sharing your experience curve. You may have helped a great deal of people just by these tips. Good job.
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