Winning the Funding Battle for Standing Devices

For all of us, standing is an integral part of the developmental sequence. And particularly for people with motor impairments and physical disabilities it is one of the key building blocks that leads to exploratory mobility. (Bower, E.) A child who is unable to stand may be missing out on developmental learning and interaction with the environment. We know the many benefits of standing as well: improved range of motion through the lower extremities, increased bone density and hip stability, and a reduction in spasticity. (Paleg, G.)

These benefits, important for the younger child, are no less important for the adult. And while there is strong evidence to support the use of adapted standing devices across the lifespan for persons affected by physical disabilities, obtaining funding approval for the equipment for adults can be extraordinarily difficult. Some payers actually try to deny the medical necessity of standing after the age of 14 years. So it becomes critically important how we justify the benefits of standing for the older patient. At our practice we recommend standing frames across the lifespan for our patients, and the denial rate we see is no larger for one group than another.

 Letters of Medical Necessity

It all comes down to the clinical documentation. This is the key to success for standing coverage. In our experience there are key do’s and don’ts in creating an effective letter of medical necessity (LMN). A vitally important factor often overlooked is ensuring that LMNs connect each desired accessory to the patient, and that you articulate the medical justification for each. If this information is not included in the initial submission, a stander may not be denied but it may be underfunded. This leaves the supplier absorbing the cost of unfunded accessories, and in the long run this is not sustainable. It also sets an unwelcome precedent for the payer that is hard to roll back.

Evaluating the Medical Need 

We perform comprehensive evaluations for all ages with thorough trials of the equipment options available and needed for the patient. Two documentation templates developed at the Perlman Center at Cincinnati Children’s Hospital appear at the end of this article on Rehab Management’s website. The first has a basic layout of the information discussed in this article. The second is more detailed and was designed to allow our clinicians to be more effective and improve the process from evaluation to documentation. This template is continually refined as we constantly review necessary edits and additions based on the questions we are asked by the funding agencies to further justify medical necessity.

Suggestions to Help Justify Medical Need 

From our experience, here’s what we’ve found:

• Make sure the letter remains patient-specific.
• Individually justify each component for that particular patient: why a component is necessary, what it does, and how it supports the patient’s impairments.
• Connect each component to the patient and a documented impairment.
• Make sure the justification for components matches the clinical summary (i.e., if requesting a specific stander due to knee contractures, be sure to include objective documentation of knee ROM).
• Use the evidence when applicable. There are several articles and systematic reviews supporting the benefits of standing and a standing protocol. (Paleg G, Glickman L.)
• Provide details on the objective measures you use to show the improvements expected with a standing program.
• Document subjective and objective benefits the patient received during a standing trial (pain relief, increased ROM, increased weight bearing, etc). Refer to the table below for recognized goals of standing equipment.
• It is equally important to discuss negative impacts if the standing equipment is not received. Is the patient at risk for contractures or asymmetries, or are they confined to static sitting for long periods? These negative effects can be linked back to the supporting research.

If the payer insists that a standing device is considered a non-covered item we encourage the family and provider to challenge that determination (since it’s clearly based on a flawed understanding of medical necessity). If a stander continues to be denied after repeated appeals we help connect the patient and families to alternative funding sources and community resources.

 Using Goal Setting as Justification

Here is the list of goals that we have formulated to buttress your justification for a standing device.

References

Bower E. (2009). Understanding movement, both typical and in the child with cerebral palsy. In: E. Bower (Ed). Finnie’s Handling of the Young Child with Cerebral Palsy at Home, 4th ed. London: Butterworth Heinemann Elsevier; 101-118.

Paleg GS, Smith B, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatric Physical Therapy. 2013;25(3):232-247.

Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010;3(3):197-213.

Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskeletal Disorders. 2015; 16:358

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