Writing an Investigational/ Exerimental Appeal

One of my great professional pleasures lies with writing and winning appeals for prosthetic devices. Insurance claims too frequently are subjected to the rubber stamp denial in a quest to deter patients or, at the very least, to delay payment.  This approach must work or the industry would change tactics. I abhor the thought of amputees in need of a prosthetic being bound by needless red tape.

I wish I could lay claim to the method I use when writing an appeal, but it was taught to me by my friend and podcast partner Dave. The method is brilliant in its intuitive simplicity, yet the nuances of presenting information in a specific method stacks the deck in the patient's favor. In this week's episode of amp'd, Dave and I presented the method for writing a strong appeal for an insurance denial on the basis of investigation or experimental.

One of the lingering side effects of the Medicare LCD from 2015 is the resurgence in vacuum technology denials based upon being experimental or investigation. The LCD proposal opened the door for insurance companies to change their stance on this thoroughly vetted suspension system. Although elevated vacuum has been around and accepted for more than a decade, and the benefits have been well documented in numerous research studies, patients are being once again being denied this previously accepted suspension system.

We recorded this episode in hopes of helping those who are facing experimental and investigational denials. While we based our sample appeal on a vacuum denial, the system can be tailored for any device deemed experimental or investigational. Our goal is that the tools we provided will empower patients to fight and appeal their denials. As always, we are happy to answer questions!

Cotillion Teasing

With the wonky weather this past weekend we didn't do anything of consequence.  Timmy and I played with trains for what felt like an eternity. For a little boy who is a thrill seeker, I am amazed at his focus when trains come out to play. He becomes an intent little engineer, purposefully connecting and pushing them through various tunnels and over and around obstacles. I don't really understand his delight with trains, but I have come to accept that he loves them and thoroughly enjoys my filling the role of assistant engineer. 

When I wasn't busy with trains I was on the internet, scouring for speech therapy options for Robby. In the days since the Cotillion Ball he revealed that he was teased both during the classes and at the dance because of his speech and hearing impairment. It hurts me to my core to know that he is being made fun of for something that is entirely out of his control. The fact that he was teased during a course that was supposed to instill manners and etiquette is an irony with which  I am still trying to grapple.

I cannot fix Robby's hearing, but we are going to do our best to augment his speech. As a family, we have decided to double down on therapy to try to hasten improvement with his articulation issues. After research and talking with some specialists, we have decided to proceed with Skype speech therapy. As he is getting older, I know that the opportunity for teasing will only increase. We are going to be enrolling him in an intensive program to try to minimize the issue before middle school (gulp).

Scott and I are walking a fine line between supporting Robby's speech endeavors without making him feel inadequate for having an issue. My normally secure little Koopa has become sensitive about his speech differences. More than one time we have stopped him from skewed self- assessments. Every time I hear him refer to himself as "stupid" or "dumb" I want to wrap him in a bubble and remind him that he is perfect to me. I know that isn't what he needs to hear, especially at ten years old, so instead we acknowledge that he has trouble making some letter sounds while discussing his many cool talents and abilities.

While I expect that he may always have some mild articulation issues, I'm optimistic that we can normalize his letter sounds in the coming weeks. Through intensive "speech boot camp" I'm hoping that Robby will hear progress and take pride in the fact that he is tackling an issue head on. He is a strong, smart and caring young man. Together, we're going to tackle those silly /r/, /s/ and /y/ sounds.

The Ball

Last night was an exciting one in our house. Robby's cotillion season (yes, apparently the course is referred to as a season) came to a close with the much anticipated Black and White Ball. He was excited and nervous all day, scared that the girls would say no when he asked them to dance and fearing that he would spill water on his rented tux. I reminded Robby that he was obliged to ask and that the young ladies were probably obliged to accept. Knowing that they would be forced to dance with him somehow eased his worried mind.

I thought it was adorable that he was so worried about dancing with a girl. Meanwhile I was worried about him breaking into fits of giggles when they formally welcomed him to "The Ball." Up until last night, he couldn't hear the term without turning red faced and breaking into peals of laughter. We actually practiced hearing "The Ball" without reacting so that he would be prepared.

Dressing him in his tuxedo was a feat worthy of a comedy routine. Neither Scott nor I have experience with tuxedos, and trying to wrangle one onto a squirming 10 year old was difficult at best. I took the back and Scott took the front, but it still took us nearly 20 minutes to dress him. Frustrated and worried about time, we told Robby to put the silver cuff links in his pocket to worry about later. His jacket extended over his sleeves, so we figured he would be okay.

Still, despite our best efforts Robby still looked awkward in his tuxedo. The vest fell too high on his waist, exposing the bleached white shirt underneath. Not knowing what to do, we advised him to suck in his gut and to deal with it. I explained that obviously they measured him wrong and provided the wrong sizes but that we had no choice but to make it work. 

Scott and Robby headed to the Ball while I stayed home to take care of Timmy.  About 30 minutes after they left I received a text photo from Scott with the explanation that the photographer fixed his tuxedo.  It wasn't the wrong size; it turns out that his parents are just idiots who couldn't figure out a tuxedo. 

Robby quickly threw us under the bus as they fixed his attire, explaining that his parents "had a hard time figuring out this cockamamie costume. For $100 it should have come with instructions or something. I mean really, that's a lot for one night." Lovely. Thanks, Robby the Parrot. And any hopes of maintaining family dignity evaporated when he pulled the cuff links from his pockets and asked what he was supposed to do with these "useless button thing-a-ma-bobs." 

Despite the dressing fiasco, Robby had a great time. I'm not sure we are meant to be a Cotillion family, but these lessons were good for him. At least he now knows how to put on a tuxedo which is a skill his parents lack.

Fun Play Day

Our midweek vacation has come to a close, and today everybody is returning to school. I know that both Robby and Scott are bummed that the snowfall wasn't enough to yield more than a two day respite. This winter has been a weather bust, but at least they had a little snow day magic.

Robby spent almost all day playing outside with his friend Rowan from down the street. We haven't seen her since September, but the snowy roads meant that her various extracurricular activities were canceled and she was able to play. Robby was over the moon when he saw her trudging down our driveway with sled in tow. Normally a multi-step process, he managed to throw on his winter gear in record time before running outside.  He finally came home at 5:30, frigid and famished.

I was delighted to watch him playing outside, laughing and having so much fun. Despite being busy with taekwondo, he has been lonely since his friend moved away last summer. While it turns out that his moving was actually a blessing, Robby has missed having somebody to buddy around with outside.  The pair get along well and have similar personalities. I'm certain the only reason that their friendship isn't stronger is because they lack the opportunity to get together.

Rowan excitedly told me that her schedule is easing up and that she will just be playing on one softball team this year. Most years she travels out west to stay with her grandmother, but this year she will be home during the summer. I'm hoping that she will be around so that Robby will have a friend to play with in the neighborhood again.

There is something special about having a friend live down the street. Being able to hop between houses and play all day through the neighborhood is something that Robby has been missing. He hasn't complained, yet I know that he has been lonely at times. As much as I try, I am a poor substitute for a neighborhood friend.  I'm keeping my fingers crossed that her predictions are true and that she will indeed be able to play more frequently. Personally, I think it would be beneficial for all involved.

Snow Day 2

Happy Snow Day #2.  Needless to say, all three boys are delighted with the prospect of another day at home. Okay, Timmy doesn't really understand but again he was more than willing to participate in the celebration when the schools announced the closings. 

Compared to the predictions, our "blizzard" definitely failed to fulfill expectations. Despite the lackluster showing, we did receive enough snow to thoroughly coat the ground and to provide hours of amusement for the boys. The roads are fine (according to Scott who fled the chaos three separate times to go to the store) but the school systems were not able to adequately clear the parking lots and walkways. So, we have another snow day to relax and enjoy the benefits of being a teacher (Scott) and a student (Robby). 

Timmy thoroughly enjoyed watching the snow, and was fascinated when we took him out to explore. He didn't want to go sledding, but was more than happy licking snowballs and watching his brother play. I think he may need a few more snowstorms under his belt before he fully understands sledding and all of the snow fun available. I'm sure by next year I won't be able to keep him inside!

After a quick tromp through the snow in the morning, I spent the majority of the afternoon baking. I love filling the house with the aromas of freshly baked bread and cookies when everybody is home because of snow. It just makes everything feel cozier and warm when treats are lining the counters. After the cookies cooled, Robby donned his snow garb and took off through the neighborhood, delivering cookies to Mr. Bill and his friend down the street. I think that they have become accustomed to my baking tradition because neither seemed surprised by the treat delivery. 

I'm sure that Robby will resume playing in the snow today. He needs to make the most of this snowfall, because it is going to be a long time before he has the opportunity again. I hope.

Snow Day!

Snow day! 

After a winter yielding disappointing amounts of snow fun, the boys are finally enjoying their first snow day of the season. With both schools making the call to close schools early in the evening, everybody was able to get into the snow day spirit early. Timmy, unaware of the reason but wanting to be included, joined the fun by jumping up and down and squealing along with his brother and Daddy. I really wish I had captured a video of their little dance, but to be honest I was too busy participating. Sometimes you just have to stand up and dance with your family!

 

Yesterday, in anticipation of the snowfall, I readied all of the sleds. Mr. Bill helped me wax the rails on Robby's so that it glides easily down the hills. Timmy's brand new toddler sled was taken out of the basement and the bottom was treated to a quick wax. (We didn't want to make it too slick because I don't want my little daredevil to slide too quickly. We plan on him being pulled rather than sledding independently, so I wanted a little assistance.)

 

Right now the sun is starting to rise, and Timmy and I are the only ones awake. I'm sitting by the fireplace, sipping on a cup of coffee while he is peering out of the window loudly oohing and aahing of the odd white coating on everything. He even retrieved Puppy Blanket and his elephant so that they could have a look out the window. (It's absolutely adorable!)  I am certain he doesn't remember snow from last year but it probably won't take long before he wants to go outside to check it out. 

 

Typically March snowstorms are frustrating because we are tired of the snow routine. This year is different because it is the only snow we have seen this year. It isn't the biggest snow that we've encountered, but it is definitely a welcome event. I know that the boys are going to love playing in the fluffy cold wonderland.  It's a good thing I didn't put the hot chocolate machine away yet, I have a feeling it will be fired up at least a few times today.

 

Perspective

Scott and I moved into this house in January 2005. We were newly married and childless, yet I instantly envisioned raising a family in this home. We loved the small stream trickling at the bottom of the woods, the big windows and the exposed beams in the living room. From the moment we moved in our first boxes, I knew that I was going to create a memory wall in the living room. 

Time went on, children were born and I became busy with work. Photos were piled and moved into boxes instead of being displayed. I knew that someday I would work on my wall, but time was always in short supply.

With Timmy and I on germ lock down, I found myself with both the time and the motivation to finally create my wall. I spent hours framing and hanging our photos, some posed and some casually captured, on my memory wall. I am almost done with the existing photos, but I am loving the results. In the early morning, while Timmy is drinking his milk and watching a cartoon, I find myself looking at the wall and smiling. If my children ever lament their childhoods, I am just going to show them the wall, filled with wonderful memories and adventures.

As I was digging through boxes, I found a slew of photos from years before I knew Scott. Many I put into boxes and labeled for another time. Some, mostly of family members and a few friends, were hung downstairs in the new playroom.Robby enjoys looking at the photos of my more youthful years, and is quick to point out nuances that he notices. 

One particular photo has struck his interest, but not for the reasons I expected. The boardwalk "Old Time" photo (something I try to do whenever possible) captured my friend Tammy and I when we were fresh out of college. I thought for sure that Robby would remark on the slightly saucy outfit I was wearing (we chose the wild west cantina girl costumes). While I was correct that it was my appearance that struck Robby as odd, it had nothing to do with the costume I was wearing. 

The photo was taken in 1996, before my foot was injured. This snapshot was the first time Robby has ever seen me with two biological legs. I was taken aback by his revelation, but upon further reflection I guess it makes sense. While I'm sure I have some pictures tucked away in photo albums somewhere, I don't have full body photos of myself (especially pre-injury) displayed. All of the photos of my childhood, college years and early adulthood tend to be focused on my face.

He viewed the photo as a curiosity not because I was twenty years younger, but because it showed a part of me that he had never before seen. It definitely feels weird knowing that my son had never seen my biological leg. Sometimes it is refreshing to be reminded that, in his eyes, my being an amputee is just who I am and is neither unusual nor an oddity.