OK…I have to get this off my chest…many of my friends/family/therapists are saying, “Be happy.  You’ve been approved.  Josephine is getting her specialized stroller.”

But I can’t.  The next question is, “Why?”.

Semantics!

I can’t get over the fact that Oxford has NO idea who Josephine is, or care for that matter.

They denied her authorization for the Kimba stroller the first time, claiming a typical stroller suits her just fine.  Yet, they have no knowledge on which to base this decision.  We submitted genetic test results and a wonderful letter written by our PT and to that they say, “Coverage for specialized strollers for infants and toddlers under the age of 3, whose transportation needs can be adequately served by regular strollers, are not a covered benefit under your health plan”.

So we appeal with another letter, this time written by Sheldon and I (mostly Sheldon).  Low and behold…APPROVAL!  We have had our faith restored in the insurance company.  Funny thing though.  I noticed the approval is based on a pediatric “wheelchair” description.  That’s odd, I think to myself.  But dismiss it because WE GOT THE STROLLER!  That should be the end of things…but it’s not.

3 days later, I get another letter from Oxford, stating, “We have considered the information submitted in support of your appeal.  The denial remains upheld as not a covered benefit under the health plan.  The Medical Director/Consultant who participated in this appeal review is a physician who specializes in Internal Medicine”.

Confused?  So was I.  Until I called Allcare Medical.  My heroes!  When the first denial came through, Allcare Medical resubmitted our request as a “pediatric wheelchair” instead of “stroller”.  Thank God for Allcare!  They know how to work the system and get what they want and what the patient needs.

But what gets me is who the heck is this Internist that denied the appeal?  Why an Internist?  Shouldn’t the decision be made by a Developmental Pediatrician or at least a Pediatrician, at the least?  RIDICULOUS!

And what about the semantics of “stroller” vs. “wheelchair”?  ARE YOU KIDDING ME?  All we had to ask for was a wheelchair and we wouldn’t have wasted so much time trying to get approval for a stroller…REALLY??!!!

So much for trying to do things the right way.  I continue to be amazed by all the work that is expected of us as parents of a child with special needs in order to get what we can for Josephine.  As if we don’t have enough on our plates:  you want us to write letters, jump through hoops, run around from place to place and still not get what we need and a deserve?

So…my new attitude…get what you need for your little princess and screw what is right and good!  That’s the way the insurance company and government want to play…YOU GOT IT!  The battle starts NOW!