This template letter for an adaptive stroller and adaptive car seat for your child may be useful if you are pursuing payment of these items by your insurance carrier.
Aetna paid for the stroller but not the car seat.
Aetna Appeals Resolution Team
Re: Denial #_________
Patient: _________
DOB: _________
To Whom it May Concern:
This letter is in reference to a denial of coverage for an adaptable stroller and car seat for _________. I am her pediatrician and am writing to appeal this denial, which states that this medical equipment is not medically necessary for _________. As her treating pediatrician, I verify that this equipment is not only medically necessary, but is essential for the continued medical care and best outcome of my patient.
_________ suffers from Dravet syndrome, a rare genetic syndrome caused by a gene mutation that interferes with protein development in sodium channels in the brain. The faulty sodium channel causes febrile and non-febrile seizures (mostly life-threatening status epilepticus) in previously healthy infants. _________’s genetic mutation is de novo and suggests she will present with the most severe spectrum of this disorder. There are less than 500 reports of this syndrome in the medical literature; however, since the genetic test became commercially available four years ago we are learning more about the scope and spectrum of this epileptic syndrome. Dravet syndrome is characterized by a constellation of seizures presenting during the first year of life and including frequent life-threatening status epilepticus. The syndrome is progressive and debilitating. Prognosis for Dravet Syndrome is developmental delay or mental retardation, and fifty percent of the reported children have an IQ of less than 50 by school age although all of the children are born as typically developing. Twenty percent of patients with Dravet syndrome die before age 20 years old of Sudden Unexpected Death or accident. Seizures, inflammation, changes in neurochemicals with the cerebellum, and brain damage from prolonged seizures at the cellular level are all probable explanations for the cognitive deterioration these children experience over time. Fatal accidents and injury occur often due to the lack of the child’s ability to develop appropriate fear due to their cognitive deficits. In addition, ataxia and atonic seizures increase accident.
The sodium channel mutation affects the cerebellar cortex and causes motor planning dysfunction, hypotonia, and abnormal gait. _________ often falls or looses balance. Modest elevation in body or outside temperature is a common trigger for seizures. _________ is _____inches tall and is too large for a “stroller” or a standard tether strapped car seat. _________ needs the tether car seat because she gets out of her car seat and does not understand the danger of getting into the front seat or riding without a car seat due to her cognitive impairment.
In summary, an adaptive stroller is medically necessary for _________for these reasons:
1) He/she fatigues easily and fatigue triggers seizures episodes.
2) When walking long distances, her temperature elevates (this is exacerbated by an anti-epileptic drug he/she takes, topirimate, which prevents sweating and raises body temperature). Elevated temperature precipitates seizures.
3) During periods of elevated seizure activity, _________ often falls and sits on the floor. _________ needs an adaptable stroller when he/she is unable to walk.
An adaptive car seat is medically necessary for Holly Harrison for these reasons:
1) _________ is ______ inches tall and the tether car seat commercially available is too tight for her. Constraints and discomfort precipitates seizures.
2) _________ is cognitively unaware of dangers associated with riding in a car that is moving without a seatbelt. _________ gets out of the car seat when not tethered and roams around the car and into the front seat while the car is moving.
3) Should _________ have a seizure in the car, which happens often, it is safest for him/her to be tethered in a car seat so the driver can see her. When using a lap belt, _________ falls forward and out of the seat. This is dangerous as it often takes up to a couple of minutes for the driver to safely exit a freeway to care for _________.
Thank you for your attention to this matter. The request for this medical equipment was submitted to Aetna as primary insurer in September. _________’s needs continue to be unmet.
Please do not hesitate to call me with questions or for additional information.
Sincerely,
xxxxxxxx, MD