Within the past few years, there has been a push for health care consumers (ie patients) to be proactive about their own health care decisions. Patients are encouraged to be more candid in disclosing information to their physicians and to ask more questions to get the quality treatment they deserve. This approach may be effective in dealing with physicians, but what happens when patients are up against a health care industry behemoth, such as an insurance company?

Deanna VanHook is a paraplegic patient who was severely injured in an automobile accident in 1984. For more than 20 years, she has been pushing a manual wheelchair, which has led to her shoulders being damaged. She and her husband recently took out a home equity loan to buy an iBot 4000 Mobility System, by Independence Technology LLC, Binghamton, NY, for $23,900. The iBot is a high-tech power wheelchair that allows the user to raise themselves to be eye-level with standing persons, reach high shelves, go up or down stairs, travel on uneven terrain, and even climb curbs up to 5 inches high.

An article in a recent issue of The Virginian-Pilot¹, reported on VanHook's plight to get reimbursed for the $23,900 she spent on the iBot. Physicians—and an independent medical reviewer by Tricare, VanHook's health insurance company—agreed that the iBot is a medical necessity for VanHook. Tricare, however, rejected the claim, calling the chair a "luxury" and stating that the cost was "non-advantageous to the government," according to a letter that the VanHooks provided to The Virginian-Pilot.

The VanHooks continue to challenge Tricare's decision, vowing to "fight to the death." They have since hired an attorney who specializes in disability rights. Through the battle, the VanHooks have found an ally in the Paralyzed Veterans of America, a nonprofit agency group based in Washington.

In its decision, Tricare's Office of Medical Benefits and Reimbursements Systems stated that "the principle behind Tricare coverage of DME (durable medical equipment) is not to enhance the personal comfort of the beneficiary, or to provide convenience for the beneficiary or beneficiary's caretaker. The intent of coverage is to provide a means for beneficiaries to remain cost-effectively outside an institutional setting."¹

VanHook's story brings to light the subjective nature of deciding on medical necessity. I'm sure that you see patients with similar conditions receiving different amounts of reimbursement for physical therapy. Who has the right to decide what is sufficient? Should there be a set of standards? How does one standardize among the differences?

What interested me even more about this article were the responses that people submitted online. Some strongly supported the insurance company, saying that this wheelchair was a luxury item and not a medical necessity, while others claimed that she had the right to demand a device that offered her full functional potential as a person with disabilities.

Does "medical necessity" allow the patient to live their life at their fullest or just at minimum functional ability? Let me know what you think.

Arati Murti

Reference

1. Young N, Wiltrout K. Couple vows to "fight to death" to get coverage for wheelchair. The Virginian Pilot. Available at: http://content.hamptonroads.com/story.cfm?story=129726&ran=24244. Accessed September 20, 2007.