HEALTH INSURANCE

I was recently denied for the purchase of a new battery for my ceiling lift. This lift allows my wife the ability to lift me from my wheelchair to the toilet, and the shower. It is simple to use, and I installed the ceiling track and lift in my home in 2010. Insurance denied the whole thing and told me that I should purchase a portable lift due to less cost. The portable lift doesn’t fit around the toilet, not does it get me far enough into the shower. I appealed. I lost. I paid $9,000 out of pocket and had ceiling track installed in the bathroom, and the bedroom to help as I got weaker and unable to transfer from my wheelchair to my bed. I use the lift a few times a day, and it works awesome. If you’re curious, there are videos of me showing this life-changing piece of tech on Youtube. I posted the video to go with the letter I am mailing to Anthem BC/BS NH today in order to appeal their denial of the battery for the lift, which is around $200. Sound ridiculous? It is. I am NOT posting this for sympathy, because I will fight. I am posting this to show everyone how broken our health care system is. I am posting this because ALL OF US (if we live long enough) will need durable medical equipment from said health care system. Indeed we all need to be aware of how messed up this is. I pay (along with my wife’s employer) almost $30,000 a year for health insurance….and I am being denied a $200 replacement battery for a lift that allows me freedom to poo. What follows is my letter. I’ll keep you posted. I’m so excited, that I am posting this week’s blog a day early. Woot.

To Whom It May Concern: Oct 24, 2023

I am writing to appeal the following claim reference number: XXXXX due to the fact that I have ordered batteries for a lift in order to transfer me from wheelchair to toilet and wheelchair to shower. I respectfully disagree with your review of these batteries being NOT MEDICALLY NECESSARY. While I understand that the health insurance company may deem it inconvenient to move one’s bowels on a daily basis, I again respectfully disagree. Now, for the fine points, please see below: 

• The requested batteries are for a ceiling hoyer lift, installed in my bathroom in my home, and due to the physical layout of my house, there is not another portable lift that will enable me to move my bowels or bathe. I believe that both of these ADL’s are medically necessary.
• I have ordered these batteries for the medical purpose of said lifting due to my diagnosis of Limb-Girdle muscular dystrophy.
• Your denial #4 is the best one and I quote: “A record of why this item is needed in terms of quantity, frequency, extent, and duration.” Brilliant. Frequency? How many times do the reviewers use the bathroom each day? Hey, I’m human, so I use it “frequently” as well. 
• The item (batteries) will help me with daily life functions as stated above.
• My FAVORITE point in your letter: “be sure the item is not being ordered MOSTLY for convenience.” That’s great. Define MOSTLY and please tell me why it should not be convenient for me to move my bowels each day. I already lack the physical capability to do so in any public restroom….but at home the batteries to lift me on to the toilet can’t be ordered “mostly for convenience.” Who writes your stuff? Sack them and get some new editors. 
• LAST ONE: The item “does not cost more than a different item.” Please have your crack medical review team research in-home portable lift products and feel free to find something cheaper than the batteries I have requested through my in-network DME provider. I am happy to have your company purchase a cheaper option that will fit in my bathroom, unless it may be cheaper for you to pay me to modify my home? Widen some doorways? Redo the plumbing so I can move the toilet? Perhaps we can start a home modification business on the side where the lowest possible bidder can also decide what is medically necessary?

So glad to hear that you have denied using the CG-DME-10 guideline. Who wrote these guidelines and who says they are not the opinion of a for profit health company who doesn’t know the first thing about my ADL’s? My life? My situation? My desire to move my bowels in a convenient way? My family medical plan costs my employer and myself almost $30,000 a year. I humbly request a new set of batteries for my ceiling lift so I may shower and use the toilet, without my caregiver (wife) having to lift me. If she does that on a regular basis, she will likely experience back pain, which will force her to put through medical claims resulting in a higher cost than said batteries. 

For your medical team of “experienced healthcare professionals” to review (who are these people? Do they have advanced knowledge of individuals with physical disabilities? Can one or more of them visit my home and take measurements in case a cheaper option is found by your company when doing research? How many hours might that take?) I have also taken the liberty of filming a short video that shows the medical device in action so you can all take a look for yourself. I have included the LINK  (https://youtu.be/2MCqMgaf7uQ). You’re welcome. 

Lastly, in case anyone is still reading, I also request an in-person meeting and review if you find more reasons to deny the funding of these batteries. Since I pay almost $30,000 a year, and the batteries are a few hundred bucks, let’s sit across from each other at a table so I can educate your medical professionals on DME while we agree on what is medically necessary. We can call the media. It will be fun. David and Goliath style. 

I await your response, and, one more thing: I’ll make sure this letter is online in case it gets lost in the mail, or if anyone else wants to chime in.

Respectfully,

Patrick T. Moeschen

11/05/1972