Introduction

As technology advances, therapists are continually being introduced to new assistive and everyday technologies that can help their clients meet their daily functional needs such as parenting a new born. An example of such devices, is an adapted crib, which was designed specifically to assist and support people with disabilities in their parenting roles.  While these adapted devices easily fit within the legal definition of “assistive technology devices,” i.e., “"any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of a person with a disability,” (H.R. 4278, 2004). more is required to establish that they will qualify for funding from insurers and other health benefits funding programs.  Funding by these sources will require that these items pass two screens: that they are “medical” devices, i.e., that they serve a medical purpose; and that they are “treatment,” i.e., that they are medically necessary.  Equipment that cannot pass both screens will not be funded, thereby limiting the ability of our clients to obtain the technology that they need to participate in meaningful roles.
A case study discussing the process of obtaining funding for an adapted electronic crib for a parent with a spinal cord injury will be used to describe the process.

METHODS/APPROACH

Although there are many health benefits funding programs, a common review process can be used to assess whether or establish that a specific type of care must be provided.  This review process is based on 4 questions:  is the client a beneficiary or participant of the program; is the care – equipment item – sought “covered,” i.e., does it fit within the scope of at least one of the program’s covered benefits categories; is the care – equipment item – medically necessary; and are there any applicable special rules that will limit access to the requested care – equipment item?  When the first three questions are answered “yes,” and the fourth is answered “no,” the funding program must approve and provide the requested care or equipment. 

In our case study the client is a wheelchair user and is the primary caretaker for her new born infant.  She is referred to an OT after reporting difficulty meeting her role as a caregiver for her baby. In particular the client does not have the balance and upper extremity (UE) skills to operate a standard crib and safely move her newborn in and out of a traditional crib for feedings, changing, bathing, play, or in an emergency.  She also reported a sense of fear that she may be seen as an inadequate parent, due to her disability, and may be at risk of having her child removed from her home.  The client asks the OT for help to identify ways she can better meet her parenting responsibilities.

OT Roles: 

The OT completes a comprehensive evaluation to identify problems that the client may have in participating in role of parenting a newborn. Barriers include that the client is unable to stand and retrieve her baby from a standard crib due to her spinal cord injury. In addition as a wheelchair user, she is not able to approach or operate a standard crib in a way that safe retrieval of her newborn is possible.  Based on the assessment the OT then researches and recommends treatment techniques and tools that will provide the client with increased independence and safety in her parenting roles.  In researching the evidence to support practice in the area of parenting with a disability the OT discovered recent research that reports inaccessible cribs are one of the current challenges facing mothers with disabilities in being able to care for their children (Wint, Smith & Iezzoni et al. 2016). Moreover, adapted cribs, and other assistive devices “increased parents’ functional care abilities and involvement, decreased pain and fatigue, and enhanced infant-parent interaction, (National Council On Disability, 2012, p.141).” As stated above the OT evaluation identified that the mother who has a spinal cord injury does not have the physical ability to stand and safely pick her baby up from a standard crib. The only way she can participate in this role is to use a piece of AT in this case an adapted crib. The crib compensates for her inability to stand and use her UE to pick up her baby- it is medically necessary “assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age. (Stover, 2016 p.2).” In her research the OT discovers a new crib technology that meets the client’s needs. The crib can be operated by an adapted remote control to raise and lower the crib to wheelchair height and the crib door can be automatically opened so the baby can be accessed at wheelchair height. The crib meets FDA approved regulations and has all of the safety features that are required for a crib. Additionally it needs a physician’s prescription in order to be purchased.

The OT and client’s physician write a letter of medical necessity to obtain the crib, which is submitted to the client’s health insurer.  The adapted crib is reported to be an item of medical equipment necessary for the client to meet her occupational therapy treatment goals, including safe and effective parenting of her newborn (AOTA, 2014)

The insurer denied the request. Some of the reasons for denial include that the product is just a crib – it is just a piece of consumer furniture and not medical in nature; the crib isn't treatment and isn’t medically necessary; and, it is a convenience item. 

Appeal Process:

To overcome the denials, the client sought the OT’s assistance with an appeal.  To be successful, the appeal had to establish that all the requirements for insurer approval were met, i.e., that the 4-question test was satisfied.  In particular, the adapted crib had to be described as “primarily and customarily meeting a medical purpose,” and “generally not useful to a person in the absence of an illness or injury,” two of the elements of the durable medical equipment benefit category.  The same facts were needed to establish that this adapted crib is not just a piece of generally available furniture.  Also, the recommendation, prescription and use of the crib had to be established as OT treatment, which is necessary to establish the crib was medically necessary and not a convenience.  In addition, the adapted crib had to be assessed against possible alternatives the client might use, such as getting an aide to perform tasks the mother could not accomplish; having the baby sleep on another surface other than a crib; and using OT services to modify a standard crib to be accessible.  The OT also researched the legal rights of the client to respond to a possible claim that due to her disability she was unfit to care for her newborn (Stover, 2016).

These issues address critical aspects of the appeal: is the crib an equipment item the insurer must cover and provide; and are the OT services used to assess the client’s needs, and possibly the OT services to modify an existing consumer item to meet the unique needs of an individual with a disability also within the scope of the insurer’s duties to cover and provide? 

COnclusion

This presentation will describe: (1) the adapted crib that was identified as appropriate to meet the needs of this client as well as other adapted cribs that are available for parents with disabilities; (2) the basis in OT guidance documents to establish that assisting individuals with disabilities with their parenting responsibilities and with identifying adapted equipment items or performing adaptations of generally available equipment items are both within the scope of OT practice; and (3) the information presented to the insurer in support of the appeal.