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
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.
- 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
- 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
- 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
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
This 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
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
Purchasing Durable Medical Equipment
- Don’t take “No” for an 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 952-937-0821or email email@example.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 will 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.
Still have a funding question that you need answered? Call our toll free funding hotline! Nancy Perlich, COTA, 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 firstname.lastname@example.org or fax at 507.697.6900.
Our Funding Specialist can:
- 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
Our Funding Specialist cannot:
- Write the Letter of Medical Necessity for you
- Fix your state Medicaid’s stander policy