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Standing Up for a Better Future After SCI

Background/ Purpose:

Many individuals with spinal cord injury (SCI) face barriers to complex rehab technology (CRT), such as limited insurance benefits, high financial costs, residential structural limitations, and identifying a rehabilitation team knowledgeable in CRT. The purpose of this case is to describe how consistent access and use of a standing frame, in addition to other various devices, have each contributed to function, health, and wellness for an individual in the years following SCI.

Case Description:

The patient is a 65-year-old male diagnosed with T8 AIS A (complete) paraplegia resulting from a car accident in 2002 after being hit by a drunk driver. Before his SCI, the patient enjoyed being active, playing hockey, and riding motorcycles. Following his accident, he utilizes a wheelchair for mobility, and his past medical history includes a right ankle fracture in 2017, neurogenic bowel/ bladder, and detethering of his spinal cord in 2007. The patient attended inpatient rehab immediately following his injury, where he was introduced to using a standing device. He continued clinical use of a standing device as he transitioned to outpatient therapy immediately following his injury to improve his standing tolerance. The patient feared atrophy and osteoporosis, and his goal was to maintain his pre-injury fitness. As he navigated through the rehab continuum, it became clear that complex rehab technology would be his gateway to returning to his active and independent lifestyle.

This patient received a standing frame 2.5 years post-injury (2004) and reported that he immediately began standing in it nightly. Due to exceptional insurance coverage, this patient has gained access to many different home devices over the 22 years following his injury. In addition to his standing frame, he has most notably acquired an FES lower extremity cycle, bilateral lower extremity KAFOs, an exoskeleton, and a dynamic all-terrain wheelchair that can stand and climb stairs.

Outcomes:

Because of his access to a regular standing program in his home and community environment for the past 20 years, the patient reports improved flexibility of his lower extremities, reduced chronic pain, decreased spasticity severity, and maintenance of bone health. The patient demonstrated maintenance of his T-score on his bone density DXA scan over five years from 2016 to 2021. Although categorized as osteopenia to mild osteoporosis, which is usual for individuals with SCI, his doctors were pleased with the stability of his lower extremity T-score DXA scan results.

Discussion:

Although it is impossible to definitively attribute improved outcomes to any one device because the patient receives multiple concurrent interventions, the patient reports numerous benefits from using his standing frame consistently for 20 years. He reports that prolonged use of his standing frame alleviates his tone, maintains his flexibility, keeps his bowel program consistent, and allows him to exercise in standing. He stated, “The frame is key to my overall health. It is a lifetime habit.”

Various complex rehab technologies each play an important role in the function, health, and wellness of an individual living with SCI in different situations and environments. This client is an example of how access to a standing frame, exoskeleton, FES bike, and power wheelchair have each separately and independently played a role in function and health for this individual.  This patient has separate goals with the use of each technology. He reports that his standing frame has consistently afforded him opportunities for various hands-free activities while in a prolonged stance without the assistance of a caregiver, maintenance of muscle tone with the FES bike, dynamic movement, and weight bearing using the exoskeleton when a caregiver is present, and independent access to ADLs and IADLs through his power wheelchair. As clinicians work with individuals with SCI, they can serve as advocates for patients to receive various CRT across the lifespan of an individual’s SCI to meet their changing lifestyle needs.

References:

  1. Logan A, Freeman J, Kent B, et al. Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomized controlled feasibility trial. Pilot and Feasibility Studies 2022; 8:50.
  2. Logan A, Freeman J, Kent B, et al. Standing Practice in Rehabilitation Early after Stroke (SPIRES): a functional standing frame programme (prolonged standing and repeated sit to stand) to improve function and quality of life and reduce neuromuscular impairment in people with severe sub-acute stroke- a protocol for a feasibility randomised controlled trial. Pilot and Feasibility Studies 2018; 4:66.
  3. Paleg G and 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.
  4. Valenzuela-Aedo F, Reyes-Moreno C, Balboa- Castillo T. Effectiveness of assisted standing on bone mineral density in children with cerebral palsy. A systematic review. Archivos Argentinos Pediatria 2024; e202310251.
  5. Spinal Cord Injury Centre Physiotherapy Lead Clinicians United Kingdom and Ireland (2013) Clinical guidelines for standing following spinal cord injury.
  6. Newman M and Barker K. The effect of supported standing in adults with upper motor neuron disorders: a systemic review. Clinical Rehabilitation 2012; 26 (12) 1059-1077.
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Example LMNs

Example Letters of medical NECESSITY

These sample LMNs are just that, samples. To write a successful LMN it is important to tailor it to your client’s needs. For more information about how to write an LMN click HERE.

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Additional Funding Information

Additional Funding information

Funding Hotline

Still have a funding question that you need answered? Call our toll free funding hotline! Maryann M. Girardi, PT, DPT, ATP is our Funding Specialist at EasyStand. She is available Monday-Friday 7:30am-3:30pm Central Standard Time at 877-844-1172 to answer your funding questions and provide guidance. She is also available by email at funding@altimatemedical.com or fax at 507.697.6900. 

How our funding specialist can help

  • Help you find an EasyStand Supplier or Rep in your area
  • Assist with correct HCPCS coding
  • Review the “Team Process” with you
  • Explain what needs to be included in the Letter of Medical Necessity (LMN)
  • Review your therapist’s Letter of Medical Necessity (LMN) before submitting to funding source
  • Review documentation that was denied and suggest corrections
  • Direct you towards advocates that can help with the funding appeals process
  • Help find demonstration equipment for sale or trial
  • Work with state durable medical equipment (DME) associatons on stander policy changes

Funding specialist cannot

  • Write the Letter of Medical Necessity for you
  • Fix your state Medicaid’s stander policy
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Appealing a Denial

Appealing a Denial

While the benefits of standing are numerous, occasionally, funding sources do not agree with consumer needs. Many standing devices have been paid for after an appeal. EasyStand is here to help you understand and navigate the appeals process for standing devices.

Don’t Take “No” for a answer

Appeal if denied! The consumer must start the appeals process.

Review the Submitted documentation

Was it complete? Does it include the equipment trial process and the individual’s specific medical needs? If you are not comfortable reviewing the letter of medical necessity fax it to 952-937-0821 or email nancy@easystand.com and we will be happy to assist with the review.

request an appeal in writing

This written request must be received by the funding source within a specified time frame, usually within 90 days. Send a copy of the notice of denial with the funding appeal letter and keep the originals. The notice includes necessary information such as recipient’s name, address, and ID number.

Referee with be assigned to hear the appeal

The referee may schedule a telephone hearing. Although, you have the right to an in-person hearing which is usually preferable. You can, in fact, state in the letter that the hearing be held in-person.

Identify potential expert witnesses

Such as a Physical Therapist, Occupational Therapist or Physiatrist. In-person testimony is desirable; however, it is acceptable to have testimony by phone or in a written letter of medical necessity.

Assistance from an advocate or attorney

PAAT (Protection Advocacy for Assistive Technology) attorneys are a free resource available to assist clients with disabilities and their families as they seek funding for Assistive Technology.

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Funding Codes

Coding for Funding

Types of Standers

  • E0637: Combination sit to stand frame system, any size including pediatric, with seat lift feature, with or without wheels
  • E0638: Standing frame/table system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels
  • E0641: Standing frame/table system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels
  • E0642: Standing frame/table system, mobile (dynamic stander), any size including pediatric
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Writing a LMN

Writing a letter of medical necessity

Writing a Letter of Medical Necessity A letter of medical necessity (LMN) is a detailed prescription a clinician writes and is submitted to the funding source. The letter should be consumer specific, not just a list of the medical benefits of standing. Documentation must communicate the process that was followed, the options that were considered, and the medical necessity for the requested equipment. The documentation should include all of the following:

1. A detailed letter of medical necessity (LMN) contains:

  • Writer’s expert credentials
  • Consumer’s name, date of birth, weight and height
  • History and physical exam by clinician including summary of medical condition, diagnosis/onset, prognosis, and co-morbid conditions
  • Functional and physical assessment including, but not limited to, strength, range of motion, tone, sensation, balance, ADLs, IADLs, and functional status
  • Documentation of other devices considered, and why each was ineffective for the consumer
  • Documentation of trialed device(s) and outcomes of the trial (s)
  • Justification of the model of device being recommended as well as each option and accessory required for the consumer
  • Evidence that the consumer demonstrated the ability to safely use the device independently or with appropriate assistance
  • Outline of the prescribed standing program recommendations
  • Any applicable research to support intended outcomes

2. A prescription for the device from the consumer’s physician

  • WriteThis is typically a co-signature on the LMN stating the physician agrees with the prescribed device. All appropriate medical professionals involved in the consumer’s care, as it relates to standing should also co-sign the LMN or provide additional documentation to support need. Examples include: Physiatry (Rehabilitation Medicine), Neurology, Orthopedics, Cardiology, Urology, Primary Care, Occupational Therapy, Physical Therapy, Speech Language Pathology, Psychology, etc.

3. Documentation that the consumer’s environment can accommodate the device

4. Detailed quote and/or order form for items being requested

5. Any other information required by the specific funding source

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Funding Team Process

The Funding Team

The funding process can seem difficult and sometimes even frustrating, but when you understand the process and have a team to support you, funding a stander can be much less stressful. At EasyStand we want to provide you with some of the resources to help with this process. One of these is understanding the team dynamic behind the funding process.

Consumer/end user

  • As the leader, they need to follow the progression of the funding process through its conclusion
  • Choose a complex rehab technology supplier
  • Be aware of the medical need to stand or research the benefits of standing
  • Specify wants and needs for standing device
  • Trial and determine the standing device
  • Be present for the final adjustment
  • Appeal if necessary (the consumer or legal guardian must start the process)
  • Follow through with standing program (once device is received/adjusted) to achieve expected outcome

Caregiver/family

  • Assume the role of the consumer (if consumer is a minor or unable to perform the task)
  • Provide support and feedback to the team on transfer techniques/activities of daily living, etc.

Rehab technology supplier

  • Provide trial standing device or request a demo with a local manufacturer’s rep
  • Offer expertise on standing device and available options
  • Acquire prior authorization with the funding source
  • Assemble, deliver and adjust device for proper fit
  • Assist with the appeals process as necessary

Clinician/Physician

  • Determine medical clearance for the consumer to stand
  • Clinician recommends weight bearing/standing device and program
  • Clinician reviews standing device options and makes recommendations
  • Clinician writes the letter of medical necessity(LMN), including trial process
  • Physician usually co-signs the therapist’s LMN or writes an additional prescription
  • Clinician usually attends and assists in the final adjustment of the standing device
  • If the standing device is denied, clinician writes addendum or new LMN and/or attends appeals hearing
  • Clinician should monitor the client’s ongoing standing program
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Funding a Stander

Funding a EasyStand Stander

Standing devices are considered Durable Medical Equipment (DME) and are categorized as Complex Rehab Technology (CRT). These devices must be individually assessed and configured for best outcomes. They are designed to support a consumer, regardless of age, in a standing position.

Step 1

Therapist and/or Physician determine medical necessity for a standing program. Before initiating a standing program, medical clearance is critical for the consumer to stand. Clinical data, and a review of relative risks and benefits of use, determine medical necessity. This information is gathered through clinical assessment and should, at minimum, include the following:

  • Consumer data
  • Physical findings
  • Measurement

Step 2

Rehab Team determines the most appropriate standing device for the consumer. Using the assessment data and goals for the consumer, consider all standing device options and select the device that is the least costly, equally effective alternative.

  • Therapist and Consumer schedule an appointment to trial the selected type of standing device. Involve a complex rehab technology supplier (and possibly manufacturer’s representative) to ensure appropriate set up of the trial equipment.
  • Based on the results of the trial, determine the specific model of standing device required and necessary support and alignment options.
  • Ensure the consumer/caregiver is able to successfully utilize the device and its features and will work in all intended environments.

Step 3

Gather necessary documentation from the Rehab Team for product justification. Requests for authorization of standing devices are typically submitted by the CRT supplier and must be accompanied by clinical documentation from a licensed physician or occupational or physical therapist. The writer should establish their expert credentials by describing: expertise, licenses, education, current job title and years of experience at the beginning of the LMN. Documentation must support the medical necessity for this equipment.

Step 4

 Payment decision is received from funding source.

  • Approval: Payment approval is granted – the supplier will order the equipment and schedule delivery with the consumer and prescribing clinician.
  • Denial: If faced with a denied claim, always appeal the decision.

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Dempsey – Achondroplasia, Cerebral Palsy

Brief description of environment of facility/school

Dempsey is seen by his school district’s Early Intervention team, with visits from the Physical Therapist twice per month as primary service provider with consultation from Early Childhood Special Education teacher and Service Coordinator.

Basic Info about client

Clients Name – Dempsey
Age – 10 months
Diagnosis – achondroplasia, cerebral palsy
Brief history – Dempsey’s mother experienced premature preterm rupture of membranes (PPROM) at 31 weeks, 3 days gestation and was hospitalized. Dempsey was delivered at 34 weeks, 1 day gestation with birth weight of 2400 grams. His Apgar scores were 3 at 1 minute and 8 at 5 minutes. He required positive pressure ventilation with oxygen and had ongoing care in the NICU for respiratory distress syndrome. MRI indicated severe hypoxic ischemic injury, multifocal cerebral, cerebellar, and intraventricular areas of microhemorrhage. Continue reading Dempsey – Achondroplasia, Cerebral Palsy

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Eli – Cerebral Palsy

Basic Info about client

Client’s Name: Eli
Age: 2 (will be 3 on 4/2/15)
Diagnosis: Cerebral Palsy
Brief history:
Premature birth – 35 weeks gestation
Sustained intrauterine ischemic event with damage to left parietal lobe, right occipital lobe, Macrodactyly left foot
Current Situation: Eli’s primary means of independent mobility is crawling with a non-reciprocating “bunny hop” pattern. He crawls up and down stairs and pulls to standing independently. He has decreased function of his right upper extremity, but consistently uses his right “helper hand”. Spasticity is present through both legs and right arm. Eli demonstrates typical crouch gait alignment in standing, tending toward bilateral ankle plantarflexion, and flexion at both knees and hips. He propels a gait trainer with minimal assist with forearm prompts and does best with ankle prompts to minimize scissoring and anterior rotation of the left side of the body. He requires verbal prompting to step to or step through with his right foot. Eli has bilateral Ankle Foot Orthotics (AFOs) to assist with alignment of his feet and lower legs. Continue reading Eli – Cerebral Palsy