Medical Denial Partly Reversed — But Not for Wheels

Advocate says …

Seven months ago I went to get my daughter’s wheelchair yearly maintenance done, and since then, it has been a long hard battle just to get her wheelchair fixed.  Her tires were so bad, that you could see the core through the rubber. She did get some temporary tires due to the kindness of the DME provider. There were some additional parts that needed to be done to keep her wheelchair operational and her safe in the chair. Since February of this year I have been going back and forth with Sunflower to get the necessary maintenance for her wheelchair.

I was told in advance that we would probably be denied the parts because of the way the fee schedule is set up through Sunflower and that proved to be correct. It took 7 months to get the denial process, since they didn’t even allow a Prior Authorization to be submitted to do a denial.  After many months of burning up my daughter’s case management hours, talking to the Care Coordinator, and the Ombudsman, I finally got the denial letter. They approved the wheelchair labor but denied some of the wheelchair parts, mainly the tires.

I did file an Appeal regarding the denial and received a notice that they requested an additional 14 days to review the information. After their 14 day period, I finally got a response back that they are reversing their decision and will allow the parts to be paid.

The DME providers are doing the best they can, but the system for maintaining wheelchairs is a nightmare for a consumers. If this happens to anyone else, please make sure you contact the Ombudsman and file an Appeal through your MCO. Like SSI it seems that their motto is to deny first.

2 thoughts on “Medical Denial Partly Reversed — But Not for Wheels

  1. Marla Flentje

    This story turns logic on its head and is a clear signal of MCO tactics and obfuscation to reduce services. I am so very sorry for this situation for you and your daughter.

  2. Cathy Pechin

    I agree that this is a clear signal of the MCO tactics to reduce services. This is typical of for profit companies to deny one what they are due in the hope that the person will not either have the knowledge or ability to press the issue. For many people with developmental disabilities, there is no one that truly cares enough to advocate for the person so this should work for them. You wonder who takes these jobs where they know that they are denying someone a product or service that the person needs and is entitled to. Seriously, if anyone expected anything else other than denials and cuts………………


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