Guest blog post by Bob Vogel
Two questions I’ve frequently been asked at consumer shows is, “How often should I replace my cushion?” and, “How often will insurance pay for a new cushion?” These are important questions. Every brand, make and model of cushion will break down over time. When this happens the cushion no longer supports and protects your skin the way it was designed — putting you at risk of a pressure sore. It is important to replace your cushion long before this happens.
A good rule of thumb is to replace your cushion every three years — which is how often most insurance companies will pay for a new one. To arrive at this answer, I turned to Dave McCausland, Senior VP of Planning & Government Affairs for The ROHO Group. McCausland says in general, Medicare sets the trend for how often a new cushion will be paid for — Medicaid and private insurance companies tend to follow Medicare’s lead. McCausland has studied Medicare guidelines and says although they don’t specify an exact length of time on how often they will pay for a new cushion, he is confident they will pay for a new one ever three years.
Another reason to request a new cushion every three years is that the ordering process is slow. It’s much better to be evaluated by your clinician and order a new cushion while the cushion you are sitting on is still in good condition and you are in no hurry. Waiting too long to order a new cushion may risk developing a pressure ulcer from sitting on an older cushion that may be breaking down. Getting a new cushion every three years has other benefits as well. You can keep your old cushion for back-up use, use it as a spare to sit on while you are cleaning your newer cushion, and you can place it on the seat of your car for extra skin protection.
Sometimes circumstances require a new cushion before 3 years. It is crucial to check the skin on your butt with a mirror every evening and every morning. If you start seeing that your skin is red after a long day of sitting, it is important to ask your doctor for a referral to a seating clinic for a seating evaluation with a clinician — a PT (physical therapist) or OT (occupational therapist).
“Anytime the cushion you are on is proving ineffective at protecting your skin you should look into getting a cushion evaluation for a new or different cushion,” says Jim Munson, District Manager for The ROHO Group. Munson adds that anytime you have a documented change of medical condition that effects your skin, such as weight gain, weight loss, or the cushion you are on is no longer effective, insurance should pay for a new cushion.
So three years have passed and it’s time to get a new cushion — how do you go about it? First of all — be a squeaky wheel — ask! Munson says the usual, and easiest route is to go to your local DME (durable medical equipment) supplier and tell them you need a new cushion — they will be happy to guide you through the step-by-step process of getting a cushion based on your seating needs.
If you don’t already have a working relationship with a DME supplier, locating one is your next step. ROHO makes this easy. To find a DME supplier go to www.therohogroup.com/where_to_buy.jsp and click on Buy from an Authorized Retailer Near You.
You can find Medicare DME provider(s) in your area by going to www.medicare.gov On the main page pull down Resource Locator, scroll down to Medicare Supplier Directory, from there type in your zip code and hit submit. On the next page check Wheelchair Seating/Cushions and hit view results. The “default” setting on View Results is 10 miles — to find more DME supplier options it is helpful to expand the View All Suppliers Within (on the right side of the page) to a larger distance in order to find a Medicare DME provider that is also a ROHO authorized retailer.
Your DME supplier will team you up with an ATP (Assistive Technology Professional) certified through RESNA (Rehabilitation Engineering and Assistive Technology Society of North America). It takes experience, training and testing to earn an ATP certificate. It is a cool idea to ask the person working with you with if they are an ATP — a certified ATP will be proud you asked.
The ATP will gather your information, current wheelchair, cushion, insurance information, etc. They will contact your physician and get a referral for a clinician to do a seating evaluation.
The goal of the seating evaluation is to find out if your present cushion is still appropriate, or whether your body changed that may require an adjustment in cushions — say going from a ROHO® LOW PROFILE® Cushion to a ROHO® HIGH PROFILE® Cushion. Following the seating evaluation, the clinician takes the information and writes a Letter of Medical Necessity to submit to the insurance company for your cushion.
As I mentioned in an earlier blog, Why You Need to Ask For Your Cushion by Name during your seating evaluation it is vital to speak up and tell the clinician that the Letter of Medical necessity and the doctor’s prescription needs to include your exact seating needs, for example ROHO® HIGH PROFILE® Single Compartment Cushion (4″). Make sure that the dimensions of the cushion needed is included on the prescription, for example 16″ x 16″. This ensures your new cushion is the exact cushion you need and expect.
From there the ATP gathers and organizes all the documentation and the DME supplier submits the paperwork to the insurance company for approval. If all goes well your cushion is ordered and you are soon styling around on a new cushion.
Bob Vogel, 51, is a freelance writer for the ROHO Community blog. He is a dedicated dad, adventure athlete and journalist. Bob is in his 26th year as a T10 complete para. For the past two decades he has written for New Mobility magazine and is now their Senior Correspondent. He often seeks insight and perspective from his 10-year-old daughter, Sarah, and Schatzie, his 9-year-old German Shepherd service dog.