August/September 2002

Taking a Stand

By Kay Ellen Koch, OTR/L, ATP

Ambulatory people usually don’t think twice about the ability to stand and the role it plays in their daily lives. The physiological improvements gained from standing and standing’s effects on social and vocational activities are much discussed and researched.¹ As rehab professionals, we understand that standing provides an alternative option for positioning and pressure relief for those who use wheelchairs. We realize the positive psychological benefits, particularly in self-esteem, for our clients who use standers. While this philosophy has not always been shared by some funding sources, it is improving. The key to reimbursement is to continue educating the funding sources on the importance and medical necessity of standers for clients who do not stand independently, as well as providing documentation and justification supporting these requests.

DOTTING YOUR I’S AND CROSSING YOUR T’S

Careful documentation can increase the odds of securing funding for standers. Acquiring funds requires clear, concise documentation and frequent appeals. Evaluation and documentation are essential when requesting reimbursement for standing frames. The more medical specialists who document the need for the stander, the better your chances are of getting an approval. Case managers are strong allies when the process for approval begins, especially if they have an existing relationship with the client and understand his or her needs. They can also gather information from a variety of sources to present to the review board.

There are three basic types of standers: supine, prone, and upright. Supine standers support the back surface of the body and require the least amount of trunk and head control. Lateral supports are often needed to support the body symmetrically. They can be placed in various degrees of angle from fully horizontal to vertical, and often have trays for upper extremity support or activities.

Prone standers support the front of the body, while the user is supported in various angles. Lateral supports are combined with pads and straps for positioning the trunk, buttocks, and knees.

Upright standers are used primarily in the vertical position, by individuals who have fair to good trunk and head control. Many rehab professionals believe this is the best way for their nonambulatory clients to weight bear. There are also standers and standing wheelchairs available today that allow for mobility, both manual through self-propulsion, and power by using a joystick.

Common components to all these standers include angle-adjustable footplates, and anterior chest, knee, and head supports. Each of these components will require justification and documentation.

FIRST STEP: THE EVALUATION

The initial evaluation forms the foundation from which justification for the equipment begins. The evaluation should include information about the client’s diagnosis, range of motion, tone, sensation, and skin integrity. Current functional status, living environment, and goals for standing need to be included. The stander and a defined standing program must be integrated as part of the client’s continuing therapy or rehabilitative program. This is a good way to continue justifying the need for the equipment. These programs may assure the funding source that there are defined goals that can be met only through a standing program. It is important to record and report about the different types of standers that were trialed during the evaluation. Be sure to also include why the specific stander you are requesting was chosen as the best for this particular client. It is always a good idea to try out standers at both the high and low end of the spectrum. There may be limits on the dollar amount that a funding source is able to provide. This will also help build your case if a more expensive stander is truly the most appropriate. During this evaluation and trial time, educating clients and their caregivers about the equipment will help with continued follow-through on a standing program once the equipment is delivered. Documentation on how long the system will be used and how many times a day or week it will be used as an integral part of a therapy program needs to be included.

Medical necessity rather than functional necessity should be the theme of your documentation. Check also to see if the primary funding source considers standers as durable medical equipment (DME), and if the client has DME coverage as part of her insurance policy. Along with medical necessity, the cost-effectiveness of the stander needs to be recorded. For example, the purchase of a stander now may reduce the need for surgery and/or extended hospital stays in the future. Cite examples of research to back up your request. Many of the major standing frame and standing wheelchair manufacturers have funding information and research articles available in print and on their Web sites.^2-4 A photo of the client standing in demonstration equipment adds an essential personalized element to your request.

If you are aware of basic home or work modifications or an environmental adaptation that may not be required if a standing frame is provided, list them as part of your documentation. For example, a standing frame may allow an individual to continue in a vocation previously held before his disability.

THE MANUFACTURER’S ROLE

Maintaining a positive relationship with your rehabilitation technology supplier (RTS) and manufacturer can make them your final allies in this process. Your supplier may have an existing relationship with the funding source and can assist you with the specific paperwork each funding source may require before it reaches the review process. The RTS can also be instrumental in the ordering, assembly, delivery, and maintenance of the equipment. The manufacturer may have a funding specialist who can assist with information to submit with your request, along with sample letters of medical justification and current research. Often the manufacturer will have a local representative who will have equipment for demonstration and evaluation.

If, despite your justification and documentation, the equipment is not approved for your client, you can always begin an appeals process. Check first to be sure it was not denied due to a lack of basic information, such as height, weight, incorrect policy number, or missing signatures. Most funding agencies have their appeals process in their policy books or on their Web site. As a rule, it is best to document your request for an appeal in writing along with the pertinent information about your client’s name and policy, group, and identification number when you resubmit your request. Always keep a copy of the correspondence in your client’s records, along with the names of the people you have contacted. If they are instrumental in assisting with a successful appeal, be sure to write them a brief thank-you note for their help once the equipment has been delivered. Building a relationship with your funding sources may make it easier for future equipment requests.

Clients, if able, should also be active in the appeals process. They may contact the funding source by phone or letter, requesting a review of the denial.

Finally, thinking outside the regular arena of funding may be required if your request is still denied. Some high school service groups, college fraternal organizations, adult civic clubs, and church groups may assist with fund-raising. There are also a few school systems that will purchase pediatric standing frames for use in the classroom as part of the educational plan. Diagnosis-specific organizations may also assist in providing funds when no other source is available.

Ideally, the physician, client, therapist, supplier, manufacturer, and funding source all work as a team to achieve the ultimate goal—better outcomes for patients.

References

1. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Brenner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther. 2001;8:1392-1399.
2. Alimtate Medical. Available at: www.easystand.com. Accessed July 6, 2002.
3. Lifestand. Available at: www.lifestandusa.com. Accessed July 6, 2002.
4. Permobil Inc. Prime engineering. Available at: www.primeengineering.com. Accessed July 6, 2002.