Julie Stalmer 7:15 p.m., June 25
- Community Blog
Who would want to replace this?
National healthcare? If it is anything like Medicare or if Medicare stays in place, it won't be much help!
So, there is this 60+ year old female. MRIs show several periventricular deep white matter lesions, small vessel disease in cerebellum. Lumbar puncture did not confirm nor did it rule out MS (Multile Sclerosis). She has severe RLS (restless legs syndrome); hyper-reflexes(4++); akathisia, a condition characterized by uncontrollable motor restlessness; vertigo; headaches (not migraine but likely related to C-spine); post c-spine (C5-6, 6-7) discectomy & fusion in 2007; Parkinsonism (R/O); Optic nerve head Drusen resulting in 50% loss of vision, lower half of both eyes; ataxia (an inability to coordinate voluntary muscular movements that is symptomatic of some nervous disorders); balance problems, resulting in numerous falls; low back pain, L-5 nerve impingement; arthritic right thumb joint & right upper extremity carpal tunnel syndrome, both will require surgery; long history of depression; obesity, due to major decrease in physical activity.
The patient's primary care physician requested approval for a motorized scooter. The Health Plan denied that request. The patient wrote an appeal, providing copies of records from her Ophthalmologist, Neurologist, & GP. That request has also been denied. Now, the records have gone to New York for review, based on Medicare guidelines. The NY company does not have a toll free number!
A call was made to the health plan. Miguel is the "coordinator" of this case. He does not make any decisions and he is the only person allowed to communicate with the patient on this matter. The medical issues and decision for denial are made by a medical director, who will not talk to the patient. It should be noted that the patient initiated all communication and left messages for Miguel, who did not return the calls. Now, as of last Friday, the claim is denied and sent to New York. Therefore, discussions are pointless as there will be no change in the health plan decision. This next stage is also supposed to be 30 days. The health plan appeal was mailed on 6/16/2009 and decided on 7/24/2009. Isn't that more than 30 days?
Apparently, the Medicare criteria requires that a scooter or wheelchair must be necessary for activities of daily living, in the home. So, the next logical question is, do the people who are approved for scooters have to pay some sort of fine if they use the vehicle outside???
This is HMO/Medicare at its finest. Given the patient's eye condition, she walks around with her head bent to see what lies beneath. This is causing major problems with her neck. If Medicare is cognizant or cares a whit about cost, it is most probable that a scooter would be less costly than further C-spine surgery and post-op physical therapy. (Miguel says he has no information on costs).
So, the patient waits. Insurance wheels turn very slowly as the patient must walk, keeping her head bent, because the HMO refuses to provide a motorized scooter, based on Medicare criteria. Our medical system is definitely broken and in need of fixing. An update will be forthcoming in 30 (doubtful) to 45 (maybe more) days.
More like this:
- San Diego Hospice euthanized — Feb. 15, 2013
- Letters — Jan. 4, 2012
- That's ok, sir, I am authorized to offer a 50% discount — July 7, 2010
- As Auntsandiego turns, a diatribe — June 24, 2009
- This Is Medi-Cal Paperwork for a Single Patient — March 7, 1996