Benjamin is nine years old. He lives in Red Wing, Minnesota with his parents and three siblings. Ben has quadriplegia and cerebral palsy and lives with occasional seizures and major reflux issues.
Ben’s mother, Carrie Quade, recently made a request to the family’s health plan for an enclosed hospital bed, recommended by Ben’s physician. The bed has head elevation to treat reflux and a hi/lo feature so his parents can help with self-care at an ergonomically friendly height to prevent injuries and back problems.
Request Denied
The health plan denied the request. One person Quade spoke with suggested that Ben could sleep on a mattress on the floor.
“I got really upset when they said that,” says Quade. “Ben is getting too big, and I’d never be able to get him off the floor. Besides, I’m not going to have my kid sleep on the floor. That’s just mean.”
Quade appealed the health plan’s decision to deny the bed, and her appeal was also denied. She then turned to Legal Aid’s Minnesota Disability Law Center. Staff Attorney Jennifer Giesen, who has 20 years of experience advocating for clients with disabilities in assistive technology disputes, took the case.
Attorney Helps to Make the Case
“I thought they had a very solid case,” says Giesen. “Carrie’s not a lawyer by training, but she is the expert on her son and his needs. My role is to figure out what the health plan is obligated to cover, work with the family and the medical team on their expectations, and match everything up so the child can get the assistive technology he needs.”
A bed with head elevation was clearly necessary to prevent choking from reflux, and leg elevation would keep him from sliding down during the night. Also, because Ben has occasional seizures, side rails and a properly fitting mattress were required for a safe sleep environment. Entrapment between a bed mattress and railings is a serious issue for people with disabilities like Ben, who has some mobility but limited motor control.
“Jennifer was amazing from the start,” Quade says. “She helped me relax about the whole thing. She said, ‘Don’t worry Carrie, we’re going to get this.’ She couldn’t give a 100% guarantee, but she was pretty sure.”
Getting Everyone on the Same Page
Giesen helped Quade and Ben’s medical team to understand exactly what the health plan was likely to cover and what they would not. She put together a new request for a bed with the exact features required by Ben’s medical condition.
“As attorneys, we sometimes have to clarify things for the health plan,” says Giesen. “The letter of medical necessity in support of the bed was written with a therapeutic justification. As a lawyer, I look at it from the legal justification. I understand the health plan’s obligations, and my job is to help them see how the letter of medical necessity meets the coverage criteria that they are obligated to follow.”
A Favorable Result
When the health plan received Giesen’s letter, they approved the enclosed bed as requested. Quade was delighted that the case settled without having to go to court. Given Ben’s medical condition, especially his risk of choking, having a new bed as quickly as possible was important for his safety.
“Jennifer really knew what she was doing,” says Quade. “I’m a working mother with four kids, and I don’t have the money to go out and hire a lawyer. I’m pretty savvy, and maybe I could have eventually gotten a bed for Ben on my own, but it would have taken a long time. It’s great to have someone like Jennifer on your side.”
