Lauren Poper and her husband live in Rockville with their two daughters. Eva, 13 months old, "has global developmental delays, cannot sit, stand, walk, crawl, eat or drink," Poper said in an e-mail to The System. After diagnosing Eva with extra-pyramidal cerebral palsy, her doctor recommended a motorized wheelchair to help her avoid scoliosis, or curvature of the spine.
That was in October. Only last week did CareFirst, which administers the Blue Cross Blue Shield Federal Employee Program (FEP) in the Washington area, agree to cover most of the cost of the $4,500 chair.
"I'm happy," said Poper, "but I wish I didn't have to contact The Washington Post" after "a hundred different people" told her she would need to buy the wheelchair before CareFirst could decide whether to cover it.
Poper, a senior counsel at the Securities and Exchange Commission, said in her e-mail that CareFirst initially "denied the claim and . . . said that it was because they don't cover wheelchairs for children under 2. . . . I filed an appeal and lost.
"I was told various things by different people," Poper said, "including that: they denied the appeal because it is not medically necessary even though they reviewed her doctor's letter (stating that without proper seating she will suffer permanent deformity) ; they never got a letter of medical necessity (I have now mailed and faxed it four times); and the chair is not medically necessary because she will not die without it."
"We typically have informal reconsideration of situations like this," said Jeff Valentine, a spokesman for CareFirst, "and it's not clear to me quite why it didn't fall into place this time, and to the extent that we dropped the ball, we'll take the blame for it."
As for what finally led CareFirst to approve the chair, Valentine said: "After our medical director talked directly with the member's physicians, I think there was greater clarity as to why this piece of equipment would not have been inappropriate for the patient, even though it does not fit the standard guidelines, so I think communication could have been improved in this case."
"I'm not saying that our customer service reps responded as well as they should have in this situation," Valentine said. "Again, part of it is FEP; current FEP policy provides very straightforward and very strict interpretation of a lot of this stuff, and so, as a major account for us, we're very hesitant to challenge that. But if we had gone back to FEP [earlier], perhaps in partnership with the member and the member's physician, I suspect FEP . . . would have been responsive, as in fact they have been, after all the details were made clear . . . ."
"I'm hoping that after this I won't have as much trouble" ensuring coverage for Eva -- who has developed scoliosis and a need for surgery to repair her right hip, said Poper. But "it doesn't seem like it will be any different for the next person" with similar needs.
-- Tom Graham
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