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Knucklehead Insurance Denials: The Saga Continues
I recently reviewed an amazing denial of a clinically appropriate prosthesis for a gentleman with an HMO-administered Medicare +Choice policy. The story in a nutshell is that this middle-aged man had documented history of multiple falls with his current prosthesis, which contained a stable polycentric knee. His physician prescribed a more stable prosthesis which the local HMO denied on the basis that it was "not medically necessary and would be considered a convenience". Despite more detailed documentation on the appeal, the HMO upheld their own denial and then immediately submitted the claim to the Center for Health Dispute Resolution.
CDHR is apparently a company who has the Medicare contract to review Medicare + Choice denials. By submitting the claim directly to CHDR, the HMO precluded the patient from adding any additional information on his own behalf, as would have happened at a regular Fair Hearing. So, the deck was stacked against the amputee already.
What was astonishing, however, was the CDHR's conclusion that "the medical record did not reveal any change in his physical condition that would require replacement of his current prosthesis". In fact, the materials submitted clearly stated, "As a result of losing some excess weight, his residual limb has atrophied and his socket no longer fits...." It appears that the CDHR just reflexively upheld the denial without even reading the documentation thoroughly!
What is really sad about this whole situation is that the patient only has an Administrative Law Judge appeal remaining, and he has been sufficiently intimidated by the HMO and CDHR's actions that he may not be willing to fight for his rights any longer. His reluctance to keep struggling is understandable, but it's a shame because I know of several other instances where other amputees received full Medicare coverage for the same type of prosthesis as his doctor prescribed.
As long as each carrier can define "Medical Necessity" capriciously, there is no way for the amputee to anticipate what prescribed care will be covered. There is also no way for the prosthetic facility to anticipate denials, particularly when prior experience in no guarantee of what will happen on the next case.
The only solution I can see would be to have Congress pass additional legislation to establish solid standards for determining "Medical Necessity" and to force carriers to follow Medicare precedents consistently. Until then, it appears that Medicare + Choice is nothing more than a "license to hunt for coverage".
On a similar note, the Orange County Register recently published an interesting article contrasting the differences between higher cost insurance and HMO coverage, written by a woman whose husband has a different policy than hers. To read Real life surpasses any drama on 'Providence', click on www.thetimesonline.com/index.pl/article?id=1150009.
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S.D.
Thank you for sharing info on the S.D.our profession will benefit greatly from sharing the hours of your work. Thanks ,John Micheal !!!
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Re: Options
Thankyou for your info. My 15 year old son started an apprenticeship in September 2003 in November of the same year he was in an accident that resulted in him losing his right arm I have been told a 4 quarter amputaion. Currently he has to... read more
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Re: Re: Options
Forequarter amputation is in many ways a special case in upper limb loss because all of the arm is absent, and only the chest wall remains. The lack of any arm remnant makes it difficult to stabilize the prosthesis and restricts the abilit... read more
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Re: Re: Re: Options
Do you have any suggestions on getting a posthetic shoulder (I am a 4 quarter amputee) that would not strap on but actually beable to adhere to an undershirt and put a shirt over it?
Please email me directly at britseth@aol.com
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Re: Re: Re: Re: Options
Unless you wear a very tight undershirt, I think any shoulder cap attached to it would likely displace and wind up being more annoying than useful. But, with an elastic shirt such as worn for active sports, this might work OK.
I'd be in... read more
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Re: Re: Re: Re: Re: Options
SO helpful...thank you. I have never seen a suspended shoulder cap like that...very refreshing! I am having a difficult time finding the writing about pads in athletic shirts...can you forward a link?
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Re: Re: Re: Re: Re: Re: Options
The URL is http://www.oandp.com/news/jmcorner/2004-06/2.asp . --John Michael CPO
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shoulder disarticulation
Hi
really good info.
i need ur help. my husband met with an accident 3 months before and lost his left hand from shoulder ( almost same as shown in the article)and left leg above knee.
i am in search for upper extremity functional pros... read more
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Re: shoulder disarticulation
Thank you for this inquiry. When both limbs are amputated on the same side, this complicates rehabilitation considerably. I would encourage consideration be given to obtaining an evaluation and opinion from a rehabilitation hospital with ... read more
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Shoudler disarticulation follow up
Very helpful article. Thanks John. Any follow up photos of the finished arm?
THX,
RK
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Re: Shoudler disarticulation follow up
I have a few photos of a S.D.finished If interested email at magur@comcast.net.
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Re: Re: Shoudler disarticulation follow up
i need information i loss my arm shoulder by sarcoma
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Re: Shoudler disarticulation follow up
No, because the patient's prosthetist always does the delivery and follow-up. But, I'll be consulting for them next month, so I'll ask how this gentleman is doing and see if I can get permission to post some "after" shots. --John Michael ... read more
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SD fitting
That was a nicely done article: informative, clear pictures, and realistically written. Thanks
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Re: SD fitting
I'm glad this short summary of many, many hours of work was helpful. Since most practitioners learn visually, I am trying to include photos that show details so the case report narrative can be brief and to the point.
--John Michael CPO
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Re: Re: SD fitting
Sr. John Michael C.O.P. Estimado John, la Sociedad Mexicana de Ortesistas y Protesistas, Asociación Civil, le agradece su participación en el "Foro de Discusión sobre la Educación de Ortesistas y Protesistas en America Latina" celebrado en ... read more
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Re: Re: Re: SD fitting
Gracias, Alberto-
I was very pleased to be present at this important SMOPAC meeting, and will be featuring it in next month's Corner.
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