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TRICARE FAMILY VOWS "FIGHT TO DEATH" TO GET

COVERAGE FOR WHEELCHAIR -- "Meanwhile, my shoulders

continue to deteriorate as I use my manual wheelchair, over

seven months after the initial prescription for the power chair."

 

 

For more on the iBOT 4000, use the VA Watchdog search engine...click here...
http://www.yourvabenefits.org/ses
search.php?q=ibot&op=and

Story here... http://content.hamptonroads
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Story below:

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Couple vows 'fight to the death' to get coverage for wheelchair

By NANCY YOUNG AND KATE WILTROUT, The Virginian-Pilot

PORTSMOUTH

Deanna VanHook is a "valued Tricare beneficiary." It says so in the military health plan's letters to her.

Her value, though, may be less than the $23,900 cost of a high-tech wheelchair - one that enables her to climb stairs, be raised high enough to change light bulbs, and keep up with her two young children no matter what the terrain. All that will be especially useful when her husband, Thomas, a Navy doctor, deploys to Iraq.

Doctors say the chair, called an iBot 4000 Mobility System, is a medical necessity for Deanna, who was severely injured in a 1984 car wreck. An independent medical reviewer consulted by the federally funded Tricare agreed. After more than 20 years pushing a manual chair, her shoulders are damaged.

But Tricare has declined to pay for the chair, calling it a luxury that is beyond the scope of the couple's medical coverage and a cost that was "non-advantageous to the government," according to a denial letter, which the VanHooks provided to The Virginian-Pilot.

The Portsmouth couple took out a home equity loan to buy the chair in March.

The VanHooks have so far unsuccessfully challenged Tricare's decision and have another hearing with the Department of Defense on the matter in Washington later this month.

They continue to fight, they said, in part because they think they're not the first military family improperly denied coverage.

"We're beyond money at this point," said Thomas VanHook, who maintains that Tricare is using an outdated regulation to deny coverage. "This is a fight to the death."

The battle with Tricare began in May 2006, when the claim was initially rejected. In 2005, the Department of Veterans Affairs decided the iBot would be covered for veterans, and the VanHooks thought that boded well for Tricare - which is the health plan for active-duty military - to cover it as well.

Plus, they always had good experiences with Tricare before, they said. Even when claims were initially rejected, Tricare eventually paid, they said.

Given the expense of the chair, it was a coverage decision that deserved extra scrutiny by Tricare, Thomas said. But the VanHooks became worried that the appeals process was taking too long.

"Can you please find out why TriCare Management Activity is taking so long to process an appeal for a wheelchair?" Deanna wrote in December to Rep. Michael Burgess, R-Texas, her home state. She wrote that Tricare had received a second appeal in August, but the VanHooks still hadn't received a decision.

"Meanwhile, my shoulders continue to deteriorate as I use my manual wheelchair - over seven months after the initial prescription for the power chair," she wrote.

The VanHooks got their answer at the end of January, No.

If the independent physician that Tricare had consulted had found that the chair wasn't medically necessary for Deanna, their fight might have ended there, Thomas said. But Tricare's decision even noted that the physician thought the iBot was a medical necessity.

"In my opinion, 'basic mobility' for this patient with paraplegia who is a mother of active young children and homemaker would include not only moving from room to room, but also going up and down stairs to perform homemaking and/or childcare activities," wrote the medical reviewer, who was not named in the document.

Tricare said it disagreed with the medical reviewer and referred the case to Tricare's Office of Medical Benefits and Reimbursement Systems for a "program perspective."

That agency repeated what the earlier denials said: The chair has "deluxe" features that "increases the cost to the government compared with a similar item without those features, resulting in cost that is non-advantageous to the government."

"Bear in mind," the report continued, "that the principle behind TRICARE coverage of DME (durable medical equipment) is not to enhance the personal comfort of the beneficiary, or to provide convenience for the beneficiary or beneficiary's caretaker.

"The intent of coverage," it said, "is to provide the means for beneficiaries to remain cost-effectively outside an institutional setting."

This response angered the VanHooks, who have since hired an attorney who specializes in disability rights.

"I'm so glad to hear that my sole purpose in life is to cost-effectively stay out of an institution," Deanna said this week.

Along the way, the VanHooks have picked up an ally in the Paralyzed Veterans of America, a non profit advocacy group based in Washington.

While veterans who qualify have access to the iBot through the VA, Tricare adding its coverage would make the chair more widely available, said Lee Page, associate director of advocacy for the group.

"The more it gets covered, the more costs will come down," Page said.

TriCare officials contacted this week said they could not comment on the case, citing patient confidentiality issues.

Deanna said she had initially dreaded having to get a power wheelchair.

Conventional power chairs are much heavier than her manual chair, which weighs about 20 pounds. She feared she would become more isolated if she didn't need friends to carry her and her chair up stairs, something that would be especially problematic when Thomas goes to Iraq.

"Her support structure, while I'm deployed, is the neighbors," he said.

While the iBot is heavy, weighing about 300 pounds, its technology allows the user to independently go up and down steps and easily traverse uneven ground. Deanna can now follow her two children, Robert, 6, and Laura, 3, wherever they go.

"Wow, this actually has the power to not limit me, plus save my shoulders," Deanna said. "It's the Holy Grail, pardon my analogy."

Nancy Young, (757) 446-2947, nancy.young@pilotonline.com

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Larry Scott  --