After two internal appeals, working with Office of the Healthcare Advocate, pulling numerous support letters and studies, a request for an external review, and 10 months later: Gavin won!! The external review committee found in his favor and reversed the insurance company’s decision to deny coverage for his stander. (For the full backstory on this see my post from September.)
We are SUPER excited and can’t wait for the official word to trickle down to the folks who process this info at the insurance company so we can get his stander ordered! Once the order is in – should take about 2-3 weeks for the stander to come in and for us to head up to Shriner’s for a final fitting/pick-up.
While over-the-moon that we won and he will be able to get the device he needs to continue his growth and development it is BEYOND frustrating that it took so much work on the part of so many different people to make this happen. By the time we actually take ownership of the stander it will be closer to 11 months since we started on this journey. That is obscene. In the reversal letter we received it clearly noted that based on his age, diagnosis and developmental and physical delays that there is no question that this device is medically necessary for him to reach his next milestone. But why did it take an external review by board certified PT and MD’s for us to reach this point?
I’m not a doctor or nurse nor do I have any medical training however I do have common sense (which I know – really isn’t so common anymore) but it seems to me that if we don’t want to pay for bigger issues down the road (surgeries and additional PT/OT from said surgeries) why not be proactive now and use the idea of preventative medicine here?! (Essentially what the external review committee noted in the letter we received.)
While I truly hope this isn’t true, I almost wonder if the insurance company sees the price tag and says, “Hey now – we’re not made of money. Let’s deny this – if we do it enough times, maybe they will just go away.” And, I would think after enough denial letters, a lot of families would do just that. While very upsetting, completely understandable. There were several times I thought, “eh, he has other devices let’s move on.” Ultimately I continued to push because he DOES need THIS particular device. Contrary to what the insurance company thought – this was NOT a device on convenience (seriously? have they ever seen what this thing actually looks like?!) By using a stander he will start to strengthen his leg and hip muscles (preventing hip dysplasia), work on head and trunk control and see life from a different perspective. While other devices can help with these things, it’s more of a by-product than actually addressing the needs the device is intended to serve.
As we settle in and wait to hear when we can pick up his stander, we’re already gearing up for another fight. See Gavin has a new “trick”. His latest and greatest milestone to date: He’s walking! (with the assistance of a gait trainer – which we have on loan from Birth-2-3). His PT wants him to get his own gait trainer so that he can use it at daycare – where he will be encouraged and motivated by his peers to walk/move. Here’s a picture of him in his gait trainer for the very first time. It’s devices like this and his stander and adaptive desk chair that are opening up his entire world. His smile and energy are just two of about a million amazing reason that keep me fighting…