GM:
Like a lot of you on this list, I have been at this for quite a few years but still come across cases where I am still uncertain and confused whether a device will considered medically necessary/reasonable by an insurance policy.
Specifically, presented with an long-time patient who contracted polio at a young age and was affected w/ Post Polio Syndrome recently. At this point, they are non-ambulatory and only able to use the orthosis for transfers. Currently using a 26 year old conventional KAFO that has been repaired/refurbished by us since that time and most likely needs to be replaced. Although we will have good medical eval documentation regarding this patient from the physiatrist and rehab clinic, I am still concerned about providing a new KAFO for transfers only and being reimbursed.
My feeling is that if using the orthosis for transfers in ADL’s will protect them from a fall, thereby preventing further injury, possibly serious, with a very expensive hospital stay, then this could be considered medically necessary. But we know that insurers can be shortsighted and not consider long term costs.
Would like to know what experiences/opinions you have for this situation?
Thanks in advance for your replies.
Eric
Eric Schwelke CPO LPO, Director
Kessler O & P Services
11 Microlab Road
Livingston, NJ 07039
Direct Tel: 917 337 7557
Office Tel: 973 863 4231
Direct Fax: 717 635 3920
“Success in Motion”
[Kessler Institute Best Hospitals Banner]
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