Funding Guide

Funding Guide

Bath equipment/Rehab Shower/Commode devices are considered Durable Medical Equipment (DME). Some of these devices must be individually assessed and configured for best outcomes. They are designed to support a consumer, regardless of age, in a supported sitting position for safe, complete hygiene and/or bowel care programs. 

Step 1: Therapist and/or Physician determine medical necessity for the equipment  

Step 2: Rehab Team determines the most appropriate Bath/Rehab Shower/Commode with the Consumer Using the assessment data and goals for the consumer, consider all equipment types and select the device that is the least costly, equally effective alternative.

  • Therapist and Consumer schedule an appointment to trial the selected type of 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 the device required and necessary support and alignment components.
  • Ensure the consumer/caregiver is able to successfully utilize the device and its features and will work in the intended environment(s).

Step 3: Gather necessary documentation from the Rehab Team for product justification Requests for authorization of bath/rehab shower/commode equipment are typically submitted by the CRT supplier and must be accompanied by clinical documentation from a licensed physician or occupational or physical therapist. Documentation/LMN 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.

ActiveAid, LLC has been a specialized USA manufacture of high quality made Bath/Rehab Shower and Commode products since 1965. The diversity of these products addresses a range of uses from basic daily care assistance- to products designed for medically complex consumers to use in the home environment. We also offer a range of product for hospital and institutional markets

or

Our products run from a basic shower/commode seats without a back to a highly configured Rehab Shower/Commode Chair – that may include Tilt, Recline, Seat Height Adjustment.

Purchasing process

The purchasing process for Bath/Rehab Shower/Commode equipment depends on the payer and the consumer’s individual policy.

Medicare and some private insurance companies consider bathing and showering to be a convenience and not medically necessary, so not covered.

If you have private pay insurance or a MediGap plan- you should check with your individual plan to determine what coverage you may have for bath/rehab shower/commode equipment under Durable Medical Equipment (DME).

If you have a state Medicaid plan, many state Medicaid’s consider Bath/rehab shower commode and Toileting Equipment to provide support and safety to individuals during hygiene tasks if they meet specific medical necessity criteria such as;

Bath or Shower Chairs, Tub Stools or Benches

Some Medicaid’s consider a basic bath or shower chair or tub stool or bench as covered without prior authorization, for the consumer who is unable to safely use the bathtub or shower in their homes. (check with your state Medicaid policy)

Rehab Shower/ commode and/ or Toileting Systems

Highly configured Rehab Shower/Commode and Toileting Systems will require detailed information in the form of a Letter of Medical Necessity (LMN) after the consumer has had an evaluation performed by a physical or occupational therapist or similar professional experienced in evaluating bath/bathing and toileting equipment. The detailed information needed in the LMN may be similar to this:

• The consumer is unable to safely and promptly access the toilet or shower in the bathroom in the home because of a medical condition

• The specific medical condition(s) that makes a commode or basic shower chair unsafe, and how the requested item will address the consumer’s medical condition(s)

• The amount of time the member will use the equipment daily

• The requested equipment is appropriate for the consumer’s height and weight

• A trial has shown that the requested equipment will fit in all necessary areas of the consumer’s home

• Details about the current equipment or how the consumer is currently bathing, and specific and detailed information about why it is no longer meeting the consumer’s needs or cannot be repaired

• Other less-costly ways to meet the consumer’s needs have been considered and why they will not meet the those needs. Include make and model of multiple less-costly items considered and rejected

Each state Medicaid determines their own DME policies within the scope they are allowed.

The Rehab Team

Consumer/End User

  • 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 use the equipment
  • Specify wants and needs for the shower(bath)/commode
  • Trial and determine the best equipment
  • Be present for the final adjustment

Caregiver/Family

  • 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, Hygiene, bowel and bladder programs etc.

Rehab Technology Supplier

  • Provide trial shower(bath)/commode or request a demo with a local manufacturer’s rep
  • Offer expertise on shower(bath)/commode and available types and components.
  • Acquire prior authorization with the funding source
  • Assemble, deliver, adjust and educate on function of device
  • Assist with the appeals process as necessary

Clinician/Physician

  • Clinician recommends shower(bath)/commode and program
  • Clinician reviews shower(bath)/commode 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
  • Letter of Medical Necessity

Writing a Letter of Medical Necessity -A letter of medical necessity (LMN) is a detailed prescription a clinician writes and then is submitted to the funding source for prior authorization. The letter should be consumer specific, with documentation communicating the process that was followed, the devices that were considered, and the medical necessity for the requested equipment. The documentation should at a minimum include all of the following:

Shower/commode chair

 Letter of Medical Necessity (LMN)

  • Date of Service:
  • Client name
  • DOB
  • Ht
  • Wt
  • Ordering Physician
  • Reason for referral
  • DX- summary of medical condition, diagnosis/onset, prognosis and all co-morbid conditions
  • Evaluating therapist expert credentials. i.e. name, title, years of experience
  • Functional/Physical Assessment; including but not limited to, strength, ROM, tone, sensation, balance, etc. How and why this client’s presentation requires the use of a specialized shower /commode chair. I.e. The client has extensive weakness, contractures, or abnormal tone requiring full body support and/or requires total assistance for transfers and bathing and/or has _____medical need that requires tilt or recline positioning, and/or requires pressure relief at all times with sitting due to stage 3 or greater pressure wound.
  • Shower /Commode History: Details about the client’s current equipment and/or how the client is currently bathing, and specific detailed information about why it is no longer meeting the client’s needs or cannot be repaired. If addressing under 21 yo client, must address growth potential of device.
  • Documentation of multiple other less costly devices considered, and why they are ineffective for the client- i.e. a short text- We considered a _________ commode/shower chairs and determined that it would not function safely for this client due to his DX of CP, presenting with lower extremity extensor tone and hip thrusting. He cannot sit upright independently must have at least 20 degrees of tilt for safe bathing… 
  •  Documentation of the evaluation and/or clinical trial(s) that determined the best device. This should include date, trial(s) information and outcome(s).
  • Documentation of required component(s) for that individual client to use the device safely and effectively. I.e.-Foot rest/plates- are required as the client has no functional use of the lower extremities or Elevating leg rest- ______condition prevents 90 degrees of knee flexion is required to support this client’s legs while bathing/toileting etc. When tilt in space shower commode chairs or custom molded seating is requested, additional documentation is required to support these options. The amount of time the recipient uses the equipment daily will be considered when evaluating the need for these options.
  • (date) and that the shower/bathtub is accessible for this device and that caregiver access to the client is adequate. Include details of the client’s living arrangement and caregiver status
  • ? __ will be using the Shower/Commode chair daily for bowel and bladder program of ______minutes. The chair will also be used bi- weekly in the shower.
  • All appropriate medical professionals involved in the consumer’s care as it relates to bathing/toileting should also co-sign the LMN or provide additional documentation to support the same need. Other potential medical perspectives include: Physiatry (Rehabilitation Medicine), Neurology, Orthopedics, Cardiology, Urology, Primary Care, Occupational Therapy, Physical Therapy,

Appealing a Denial

  • 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 nancy@easystand.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 who wrote documentation. 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.