Andi's Adventures in Bureaucracyland
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The letter is from “IntegriGuard” which according to the logo is “Getting results, Making a Difference”. They are a “Medical Review Subconractor to EDS. You apparently should know what all that means when you get a letter from them noting that only the addressee may open the damn thing. It’s confidential. Ooooooo.
The letter reads in part
“IntegriGuard received your wheelchair ADMC request [ADMC it says above is “advanced determination of medical coverage]. Based on the information submitted, we have determined that you do not meet the medical necessity requirements Medicare has established for the wheelchair base for the following reason(s):
The documentation received with your request does not support the need for a power wheelchair with power tilt.
For Medicare coverage of a Group 3 PWC [note that this, which appearly means “power wheelchair” is not explained] [note also that I did not submit the paperwork but left it to the experts – which you would too – the physical therapist consulting with the wheelchair guy], the patient’s mobility limitation must be due to a neurological condition, myopathy or congenital skeletal deformity. Diagnoses provided include metabolic bone disease, multiple pelvic fractures, significant pain, musculoskeletal deformities and L rotator cuff tear which do not fall into this category. However, documentation provided indicates coverage for a Group 2 PWC would be meet. [sic]
[note. Nowhere is a “group 2 PWC” defined in any way.]
they go on to say they want to know how I intend to get into the bathroom with the chair since we reported (accurately) that the door is 23” wide. What I wanna know is a) WHAT THE FUCK BUSINESS IS IT OF THEIRS since they have no intention of checking up on this, never have asked before and b) would they deny the chair if I don’t “address how patient will access bathroom”. They don’t offer to fix it, widen it, evaluate or assess it themselves mind you. They just think they have a fucking right to know how I will get into my bathroom, something they have not cared about since I firs went on SSDI over 10 years ago.
The letter continues saying that “when the medical necessity is not met for the wheelchair base, the medical necessity for the accessories is also not met.”
You like that? You have a clue what it means? Because I sure don’t. I don’t know what part of my power wheelchair is considered “the base” and what is an “accessory”. Is the seat “an accessory”? the wheels? The batteries? The motor? There is more to a wheelchair than the base. I know they’ve turned down the special seat and apparently will approve the standard seat. Which Scott says is not right for me and Scott has repeatedly said “let’s do it right the first time”. He doesn’t want us to settle, he knows what I should have to make this a good transition so I get the help I need. I believe him and in him. Not getting the right thing will only mean I will need it down the line and have to replace what I have, which might not do what I need it to do. It’s stupid, it’s a delay we should not be having. But if you know my history you know that I’m tired and really fed up and that I fought Medicare once and lost. On an issue that was just as stupid as this one (they won’t pay for a scooter if you don’t use it in the house. No one can say why this is so. It jus is. But they never ever say that anywhere and they make you go through the entire process without ever saying “if you aren’t going to use it in your house, do not fill out these forms. Medicare will not cover your scooter’s costs”. They NEVER tell you this. EVER. Until you submit the paperwork for reimbursement. Please do not ask why they don’t. Please never ask me how Medicare thinks, because it makes my branes hurt had then my head goes blooey.
What we have here is the government at work, a bureaucracy telling me that I HAVE THE WRONG conditions, the incorrect illnesses to qualify for the wheelchair which Scott and Clark say I need, especially Scott who is the PT expert. It doesn’t matter WHAT I DO HAVE. I don’t have the right things wrong with me.
The letter reads in part
“IntegriGuard received your wheelchair ADMC request [ADMC it says above is “advanced determination of medical coverage]. Based on the information submitted, we have determined that you do not meet the medical necessity requirements Medicare has established for the wheelchair base for the following reason(s):
The documentation received with your request does not support the need for a power wheelchair with power tilt.
For Medicare coverage of a Group 3 PWC [note that this, which appearly means “power wheelchair” is not explained] [note also that I did not submit the paperwork but left it to the experts – which you would too – the physical therapist consulting with the wheelchair guy], the patient’s mobility limitation must be due to a neurological condition, myopathy or congenital skeletal deformity. Diagnoses provided include metabolic bone disease, multiple pelvic fractures, significant pain, musculoskeletal deformities and L rotator cuff tear which do not fall into this category. However, documentation provided indicates coverage for a Group 2 PWC would be meet. [sic]
[note. Nowhere is a “group 2 PWC” defined in any way.]
they go on to say they want to know how I intend to get into the bathroom with the chair since we reported (accurately) that the door is 23” wide. What I wanna know is a) WHAT THE FUCK BUSINESS IS IT OF THEIRS since they have no intention of checking up on this, never have asked before and b) would they deny the chair if I don’t “address how patient will access bathroom”. They don’t offer to fix it, widen it, evaluate or assess it themselves mind you. They just think they have a fucking right to know how I will get into my bathroom, something they have not cared about since I firs went on SSDI over 10 years ago.
The letter continues saying that “when the medical necessity is not met for the wheelchair base, the medical necessity for the accessories is also not met.”
You like that? You have a clue what it means? Because I sure don’t. I don’t know what part of my power wheelchair is considered “the base” and what is an “accessory”. Is the seat “an accessory”? the wheels? The batteries? The motor? There is more to a wheelchair than the base. I know they’ve turned down the special seat and apparently will approve the standard seat. Which Scott says is not right for me and Scott has repeatedly said “let’s do it right the first time”. He doesn’t want us to settle, he knows what I should have to make this a good transition so I get the help I need. I believe him and in him. Not getting the right thing will only mean I will need it down the line and have to replace what I have, which might not do what I need it to do. It’s stupid, it’s a delay we should not be having. But if you know my history you know that I’m tired and really fed up and that I fought Medicare once and lost. On an issue that was just as stupid as this one (they won’t pay for a scooter if you don’t use it in the house. No one can say why this is so. It jus is. But they never ever say that anywhere and they make you go through the entire process without ever saying “if you aren’t going to use it in your house, do not fill out these forms. Medicare will not cover your scooter’s costs”. They NEVER tell you this. EVER. Until you submit the paperwork for reimbursement. Please do not ask why they don’t. Please never ask me how Medicare thinks, because it makes my branes hurt had then my head goes blooey.
What we have here is the government at work, a bureaucracy telling me that I HAVE THE WRONG conditions, the incorrect illnesses to qualify for the wheelchair which Scott and Clark say I need, especially Scott who is the PT expert. It doesn’t matter WHAT I DO HAVE. I don’t have the right things wrong with me.
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