Denied, Part 2
If I may rant for a few minutes… We received the denial of the appeal for the EasyStand sit-to-stand stander and Miniwalk walker today from the Division of Developmental Disabilities (DDD). It’s 12 pages, in part because they repeated my 6-page letter word-for-word. When they denied the equipment originally, they obtusely gave four reasons: 1. Need proof equipment works for her condition, haven’t received info from doctors or other providers showing this item helps. 2. Services must be medically necessary (that is, it must prevent disease, disability, or bad side effects or prevent the advancing of disease or prolong life). 3. Services must be cost effective, there is another item or service that costs less and works as well. 4. Basic care should be tried first. My letter addressed each point for each piece of equipment. I included letters and reports from doctors and therapists, as well as citing scientific studies.
I thought they’d stick to these 4 items, but no. They say “We have reviewed the [information] and have determined that the member appeal be denied. Our decision is based on [laws cited] that allow only medically necessary, cost effective and federally reimbursable services as covered services.” They go on to say that “it appears that there should have been two separate appeals for two separate pieces of equipment.”, even though I addressed each piece of equipment for each point in the appeal. And, my favorite part, “With regard to the Gait Trainer [Miniwalk Walker], the materials do not indicate that Maria has the potential to walk independently, confirmation of which must be received by the Division of Developmental Disabilities before a Gait Trainer can be provided.”
The only saving grace of this pile of crap is that they are recommending that an assessment be done to determine whether Maria has the potential to walk independently. I’m hoping that all they need to do is to meet Maria and they will see her potential. We’ve experienced time after time that when people read reports and test results about Maria, they don’t have much hope for her; but when they meet her they are always pleasantly surprised at how much potential she has and how well she’s doing.
The DDD’s letter also says the EasyStand sit-to-stand, in its seating position, has the same purpose as the stroller they bought us, and in its standing position, has the same purpose as the Miniwalk, so they’re not going to make a decision on that until they decide about the walker. Granted, the walker is more important, but tell me how a stander has the same purpose as a walker.
The other disturbing passage in the letter, when talking about medical necessity, says “The Chief Medical Officer reviewed the documentation submitted with the appeal and determined it does not appear the request is for rehab reasons (per the physical therapist’s note). As a result, we recommend denial of the appeal.” I don’t even know what that means, but Barb (PT) sure is going to be pissed.
I have 30 days to request a fair hearing, which I will do, although I have no idea what that entails–do I need a lawyer, for example? In the mean time, I’m going to call the DDD Health Care Services on Monday to get the ball rolling on this evaluation that they’ve recommended. Of course, as Barb said last week, if Maria’s feeling good during the assessment, she’ll do awesome; if not, then not. I’ll just have to video tape them in their next session (in 3 days) and hope Maria’s doing well, so I can show that to them. Of course, now that there’s only a few days left of school, Maria seems to be feeling a bit under the weather. She slept a whole lot of today and is coughing a bit.
And in the middle of all this, we’re filing a Petition to Remove Conditions on Residence for Manolis. He has permanent resident status (which is only good for 2 years to make sure we’re married for real and not just for a green card). It’s due 3 months before his resident card expires–although we filed the renewal of his work permit card 5 months ago (!), and haven’t received that yet, so who knows if it will be done in time. We finally got an appt with Immigration this Friday, so we’ll see if they can tell us anything about the work card. I don’t know if they’re massively backed up or if I screwed something up when filing the papers. Their instructions are so hard to follow–even for me, an English-speaking, semi-intelligent person. The challenges we’re given…..
Barb, the PT, is going to experiment with some “intensive dosing” this summer. We’ll do PT, focusing on walking, 4 days/week for 2 weeks, then take 2 weeks off. We’ll do that a few times and see if that helps because obviously walking with Barb 1 hour/week isn’t cutting it.