When the payer says "no!": ethical considerations in patient advocacy

Spinal cord injury is a relatively infrequent but often catastrophic injury. As such, it presents special challenges for the individuals affected and the clinicians who care for them. Claims for reimbursement of acute care, rehabilitation, and long-term care are often denied, requiring patients and clinicians to exhaust every effort to ensure coverage for therapeutic interventions, preventive care, and durable medical equipment. Ethical dilemmas are presented within the framework of the US healthcare system, and practical strategies are discussed.