Twice-denied for custom wheelchair cushion (E2609) — heading to external review, looking for IRO strategy
T5 complete SCI here, full-time manual chair user, history of a Stage 3 ischial pressure ulcer and . Used a Ride Designs custom cushion for 7 years with no recurrence; cushion is worn out and pressure mapping shows it's bottoming out at both ITs. Tried Jay and ROHO years ago — neither worked (no pressure relief, ROHO caused moisture skin breakdown).
OT submitted a full LMN with the new pressure-mapping findings and an updated letter explaining my flexible postural asymmetries (left pelvic obliquity, scoliosis, posterior pelvic tilt). UHC/Surest still denied twice. Final denial says "the notes do not show why custom seating is needed" and "other adjustable cushions (custom fit) can meet your needs" — without engaging with the pressure mapping, the failed trials, or the LCD L33312 standard that covers "any significant postural asymmetries." Self-funded ERISA plan, so next step is IRO external review.
Questions for anyone who's been through this:
- Anything that actually moved the needle for you at the IRO stage on a custom cushion / E2609? I have my own cover letter referencing LCD L33312 and the procedural problems with the internal review.
- Worth asking my treating doctor to fax an independent letter certifying medical necessity or should it be sufficient for me to fax them?
- Anyone successfully gotten the plan sponsor (employer benefits team) to push back on the TPA? I'm on COBRA from my old employer and considering a parallel ask to their benefits team.
Thanks — any war stories or specific tactics welcome.