More than a year ago, Benjamin’s therapists filed an insurance claim for a new shower chair. Our insurance denied the claim saying that a shower chair wasn’t medically necessary. Benjamin’s pediatrician set up a peer-to-peer review with a doctor from the insurance company hoping to overturn the decision without a formal appeal.
No such luck.
According to the doctor from the insurance company, “A shower chair is a comfort and convenience item.”
No. Showering is not a matter of comfort and convenience. It’s a matter of hygiene and all the medical issues that come about when you don’t properly take care of sensitive, bedsore-prone skin. Benjamin doesn’t need one of those $40 shower chairs from CVS. He needs something adjustable, with safety harnesses so he doesn’t fall if he has a seizure. He needs something supportive to protect his weak bones that have fractured easily. He needs something on wheels so I can get him from his bedroom to the bathroom.
All of these explanations were good enough when our previous insurance covered his last shower chair seven years ago. But now the powers that be think showering isn’t a medical necessity. Perhaps they think people like Benjamin should be happy enough with sponge baths. Or they think I should carry Benjamin into the bathroom, place him on the floor and shower him like that even though he can’t sit up independently.
Earlier this year, Benjamin started vomiting daily. After a particularly bad projectile incident, which left us both covered, I was pretty furious about the shower chair denial.
I hit the Internet to research the issue and found other folks complaining about insurance coverage and medical equipment. Someone said insurance companies wouldn’t cover anything that goes beyond the bathroom door.
I can’t stand blanket rules that don’t take the individual into account.
As a special educator, I was taught to look at each child individually in order to determine his/her needs. But that doesn’t always happen in education or in medicine.
In addition to my insurance company frustrations, the equipment vendor didn’t file an appeal and lied about it. After a second claim, and peer-to-peer review, Benjamin’s school put some heavy pressure on the vendor to do their job. In response, one of the vendor’s supervisors crafted a letter listing all the dates they’d contacted me, and what had been discussed. Then blamed me for lack of follow up.
As an advocate for both my sons, I’ve learned to keep thorough records, so it was very easy for me to cite my own dates, and provide actually emails to show their negligence.
The other thing special education parenting has taught me is to think outside of the box.
When looking for equipment I talk to Benjamin’s therapists, check companies such as Adaptive Mall, and try to visit the Abilities Expo to fully research equipment options. Although it wasn’t appropriate for Benjamin, it was useful to know that while some insurance companies won’t pay for a shower chair, they will pay for a commode. Some manufacturers make combination shower chair/commodes that insurance companies are more inclined to cover.
I read insurance companies won’t cover shower chairs because there’s no therapeutic need. That got me thinking. Benjamin receives pool therapy in school. Like the pool, the warm water in the shower helps loosen his muscles and gives him a greater range of motion. The steam helps loosen up the constant phlegm in his throat. The water also makes him laugh, which gets him to breathe deeper than he normally does. All of this helps Benjamin medically because his oral motor deficits put him at risk for aspiration and pneumonia.
So I discussed these therapeutic advantages with our pediatrician and he wrote a new justification letter for the insurance company.
By the time we resubmitted everything Benjamin was approved for Medicaid so not only did we have documented therapeutic need, Benjamin’s school hounding the equipment vendor’s supervisor, and said supervisor hustling to please, we also had primary and secondary insurance coverage.
The shower chair was approved in one day.
The long and sometimes ugly road to victory requires so much patience.
Do your research, use all available resources, keep thorough records, and remember there’s always more than one way to justify a need.
Among the many people who helped us finally get Benjamin’s shower chair, I would like to especially thank Dr. Michael Gabriel, Sophia Mamakas, and Michelle Roth.