The Braille Monitor                                                                      _______     November 1997

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Greg Trapp

Greg Trapp

Funding Closed Circuit Televisions Through
Medical Insurance

by Greg Trapp

From the Editor: Greg Trapp has been a staff attorney with the Protection and Advocacy System of New Mexico since 1992. In 1993 he taught disability law as an adjunct professor at the University of New Mexico School of Law. Closed Circuit Television Systems (CCTV's) can be helpful to some people. The following information may be useful to those seeking the means of financing this equipment. This is what Greg says:

In this era of decreasing state and federal budgets, it is increasingly necessary for blind people to explore alternative ways to fund assistive technology. An assistive-technology device is defined as any item, piece of equipment, or product system that is used to increase, maintain, or improve the functional capability of a person with a disability. If the device serves a medical purpose, it may also meet the definition of "durable medical equipment" (DME). A closed circuit television can be included within the definitions of assistive technology and durable medical equipment.

A closed circuit television (CCTV) may enable some people who are legally blind or who have low vision to read printed materials. It uses a camera and television screen to create an enlarged image of printed text. It can also enhance contrast by placing white letters over a black background. If you could benefit from having a CCTV at home, you might be able to obtain one through your private medical insurance, Medicaid, or Medicare. These funding sources should be considered along with more traditional funding methods such as vocational rehabilitation or through an employer as a reasonable accommodation. Since a CCTV can cost over $3,000, medical insurance may be the only practical way for many people to obtain a home CCTV.

For some people a properly used CCTV can be a valuable tool which can enhance productivity and independence. However, it is necessary to understand the limitations of a CCTV. Keep in mind that a CCTV magnifies only a small portion of text at a time and that usually the reader must physically move the item being read beneath the camera. Prolonged reading with a CCTV may also cause eyestrain and headaches. For these reasons reading with a CCTV can be slow and inefficient. Accordingly, a CCTV is often more appropriate for elderly persons who have lost vision later in life and who have not developed more efficient alternative techniques.

Despite its limitations a CCTV can be an effective supplement to other reading methods such as using Braille, tapes, scanners, electronic text, and sighted readers. A CCTV can be especially useful for reading and filling out forms, reading small amounts of text, and writing checks. A CCTV can also be an effective alternative to the use of large print or hand-held magnifiers.

Some school-aged children may be able to benefit from a CCTV. However, children who improperly use a CCTV could actually have their educational development impaired. For instance, there is often a strong tendency to encourage blind children to read using partial vision instead of using more efficient methods such as Braille. Unfortunately some parents find it painful to recognize that their visually impaired child is actually legally blind and in need of Braille. In addition, some school districts are often reluctant to pay for teachers who have the expertise needed to teach Braille, arguing that a CCTV (or other adaptive equipment) makes teaching Braille unnecessary. A tragically common situation is a child with a degenerative eye condition whose teacher ignores Braille in favor of having the child use her remaining vision even though the vision is likely ultimately to be lost entirely. In such a case, improper reliance on a CCTV when Braille should be taught could limit the child's ultimate Braille proficiency.

Regardless of the age of the person seeking to obtain a CCTV, the individual should be evaluated by a qualified low-vision professional to determine if a CCTV would be appropriate. The evaluation should include consideration of factors such as whether the visual condition is degenerative, whether the condition is stable from day to day, whether eyestrain will be incurred as a result of using the equipment, and whether the person can use the CCTV efficiently. Most important, the evaluator must appreciate the benefits of Braille and speech devices in order to insure that the evaluation will be balanced.

In order to obtain medical insurance coverage for a CCTV, you must have a physician prescribe a CCTV to treat the visual condition. The first step in the process is to determine whether your medical insurance could classify a CCTV as a medical device within the scope of covered services. This process is similar for private health insurance, Medicaid, and Medicare. Accordingly, because the processes are similar and since Medicare operates much like a private insurance program, this article will focus on the process under Medicare.

Medicare is divided into two parts. Part A pays for hospital stays and home health care. The latter coverage can include payment for durable medical equipment. Part B coverage can also include payment for DME, as well as coverage of prosthetic devices.

The Medicare description of DME includes devices such as iron lungs, hospital beds, and wheelchairs. In order for a device to be classified as DME, it must be able to withstand repeated use, be primarily and customarily used to serve a medical purpose, be generally not useful to an individual in the absence of an illness or injury, be appropriate for use in the home, and be necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a malformed body member. A CCTV can meet all of these criteria. A physician must prescribe the CCTV, include it in a treatment plan, and supervise its use. If these requirements are met, Medicare can pay for a CCTV as an item of durable medical equipment.

Medicare may also cover a CCTV as a "prosthetic device." Medicare defines prosthetic devices as devices which replace all or part of the function of a permanently inoperative or malfunctioning external body member or internal body organ. For instance, Medicare covers pacemakers as prosthetic devices, even though a pacemaker does not replace the heart. Likewise a contact lens prescribed after cataract surgery is also covered as a prosthetic device since the contact replaces the function of the natural lens. Accordingly a CCTV may be covered as a prosthetic device since it replaces the functioning of the damaged portion of the eye.

Once you determine that a CCTV may fall within the scope of a covered service, you must next obtain a prescription from a physician. In order to obtain a prescription, the CCTV must be reasonable and necessary. A CCTV is already recognized as a treatment for certain types of visual impairments. For example, the American Academy of Ophthalmology recognizes the CCTV as a prosthetic device. In addition, the CCTV is not a comfort item. A comfort item is an item such as a tape recorder which does not contribute to the treatment of the visual condition. By contrast a CCTV is a treatment for the damaged portion of the eye. It does not matter if you will use the CCTV for recreational reading.

Medicare also functions like most private health insurance providers in the way claims are processed. You must normally first purchase the CCTV from an approved Medicare supplier, then file a claim for reimbursement. However, some Medicare suppliers will order medical equipment while awaiting payment from Medicare. Medicaid differs from this process in that you must first obtain prior approval before you can purchase a CCTV. Medicare will send the CCTV reimbursement claim (along with supporting documentation) to a Durable Medical Equipment Regional Carrier (DMERC). The DMERC will determine if the CCTV is covered and is reasonable and necessary. Reasonable means that it is the lowest priced item that will meet your medical need. Necessary refers to the medical need established by your physician. The DMERC will then determine the reasonable cost of the CCTV.

Unlike Medicaid, which pays in full, Medicare subjects you to a deductible of $100 and a 20 percent co-payment. From the cost determined by the DMERC, Medicare will pay you an 80 percent reimbursement after the $100 deductible. If the supplier has agreed to "accept assignment," the supplier will only charge the amount determined by the DMERC. However, suppliers who have not accepted assignment are allowed to charge above the amount determined by the DMERC, and you will be responsible for the additional charge. Suppliers who have agreed to accept assignment are listed in the Medicare Participating Physicians/Suppliers Directory (MEDPARD), which you can request from the DMERC. In some circumstances Medicare may allow or require rental of a CCTV.

Requests for CCTV's are often denied. However, you have the right to appeal, and Medicare appeals are often successful when pursued beyond the initial appeal levels. For instance, as long ago as 1980 a Medicare beneficiary successfully appealed the denial of a CCTV. (Medicare Fair Hearing Decision, HIC No. 062-44-0658-A, 1980.) If you receive a denial, the letter of denial will explain the appeal process, and you should carefully meet all deadlines and follow all procedures. The appeal procedure is different depending on whether the claim is under Part A or Part B. The first level of appeal under Part B is to request a review. The next level is to a hearing officer. Since a CCTV costs more than $500, claimants under Part B have the right to continue to appeal by requesting a hearing before a federal administrative law judge (ALJ). The ALJ level affords you the greatest chance of success. If the ALJ appeal is not successful, you may request a review by the Appeals Council. The final appeal level is to federal court. The appeal process under Part A is somewhat similar but begins with a request for reconsideration. If the denial of the CCTV is under Medicaid, you also have the right to appeal. In addition, most private insurers also have appeal procedures. Regardless of the funding source and appeal procedure, you should be persistent and not take "no" for an answer.

The CCTV can be a valuable tool and has a place in the arsenal of alternative techniques. By being persistent, you may be able to obtain medical insurance funding for a CCTV. The immediate goal is to expand the choices you have. The ultimate goal is to enhance your productivity and maximize your potential.