Note: This column is for information purposes only and is not intended as a substitute for professional medical advice.

Q: I am deteriorating at an alarming rate. I started to use a cane two years ago, then added two short leg braces a year ago, then forearm crutches in July. My arms are too weak, and my hands, shoulders, neck and back hurt too much to use the forearm crutches anymore. My HMO and Medicare denied me a scooter because it is "too expensive," and they say that a manual wheelchair would meet my needs. Is there anything I can do?

A: There is plenty you can do! But first things first. We no longer recommend that polio survivors buy manual wheelchairs or scooters. If your arms are too weak and your shoulders hurt too much to use forearm crutches, you shouldn't be using a manual wheelchair or a scooter. Both put unnecessary physical stress on polio-damaged, overworked neurons, muscles and joints. Obviously the wheelchair requires that you push yourself around using your arms. The scooter is steered by holding up your arms--using your arm and shoulder muscles--and moving a "T-bar" tiller that turns the front wheel; you use your hands to squeeze levers that make the scooter move. What's more, the tiller forces you to lean forward in the seat, putting you in a forward flexed position that can cause neck and back pain (See "Your Achin' Back," NM, August 2000).

On the other hand, a power wheelchair is steered by a joystick, a small knob attached next to one of the arm rests. The joystick allows you to drive with your arms at your sides and shoulders relaxed, steering with only one hand--or even just your fingers--while sitting upright. Power wheelchairs can be fitted with special rigid backs that have adjustable foam inserts to provide the right amount of lumbar curve to give proper posture. If you have trunk weakness or scoliosis, you can get a back made from custom-formed foam to cradle and hold your body in place. And if you have upper back or neck pain or muscle weakness, you can order a shoulder-high or head-high back, or an additional head rest, that will allow your muscles to be supported and relaxed while driving.

A custom seat cushion is also important. If one butt cheek is smaller than the other, or if you have scoliosis and your upper body tilts to one side, an adjustable cushion that has separate inflatable air bladders--or foam inserts of different heights and firmness--can lift one side of your pelvis and balance your body side-to-side. Those with leg swelling can get manual or electric elevating leg rests. You can even get a special wheelchair frame whose back reclines and allows you to take your two, 15-minute daily rests breaks--or even a nap--without leaving the comfort of your custom-made chair.

Now that you know the kind of power wheelchairs that are available, how do you get Medicare and your HMO to pay? Medicare and most insurance companies use the Medicare rule: You are eligible to get a power wheelchair if you can walk only 10 to 25 feet inside the house. That means you can walk safely only from the bedroom to the bathroom. "Safely" is the operative word for Medicare services in general for polio survivors. You are only eligible for PPS treatment under Medicare if you are "falling or unsafe." So your doctors need to write letters of medical necessity making clear that (1) your legs and your arms and shoulders are too weak and painful for you to use crutches or a manual wheelchair; (2) you are unable to walk more than 10 to 25 feet safely; (3) you need to use a power wheelchair at all times inside the house; (4) your PPS symptoms are progressing and will get worse without the power wheelchair, making you even more unsafe and more likely to fall.

If you have already been denied a powerchair and are filing an appeal, get the name of the doctor at Medicare or at the HMO who will be reviewing the denial and have your own doctor give him a call. A doctor-to-doctor chat and personal appeal can often turn the tide and reverse a denial (See the July 2001 Post-Polio Forum for more tips on appealing insurance denials). Playing by their rules can allow you to beat Medicare and HMOs at their own power wheelchair denial game.