Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power wheelchair accessories including standing feature and seat elevator. Findings:  The physician reviewer found that muscular dystrophy is a condition caused by mutations in the dystrophin gene, resulting in degeneration of cardiac and skeletal muscle. Patients with this condition typically need to use a wheelchair for mobility to address issues such as fatigue and falls. Replacement wheelchairs are expected to be needed over time for with muscular dystrophy due to equipment wear and tear, which can progress to the point of breakdown. The typical life expectancy of a wheelchair has generally been reported to be up to five years. This patients records document a history of Duchenne muscular dystrophy with severe weakness affecting all extremities. The patient requires a power mobility device for all functional mobility. However, the records provided for review do not support the medical necessity of the requested standing feature and power seat elevator. Power seat elevation can potentially be an appropriate and necessary component for a power wheelchair in order to provide a user with the ability to independently transfer into and out of the wheelchair. This patients records do not establish that the patient would be independent for his transfers by using this feature. The patient requires a Hoyer mechanical patient transfer device for his transfers. There is a lack of documentation that the patient was able to independently transfer with trial use of power seat elevation feature or in equivalent conditions. Thus, the requested power seat elevator is not medically necessary for treatment of this patient.  Similarly, the requested power standing feature is not a medically necessary addition to this patients power wheelchair. There is a paucity of high-grade evidence to support that regular passive standing with use of a power standing feature equipped on a power wheelchair, provides clinically significant benefits with respect to health or functional outcomes in the setting of neurological weakness or other conditions impairing the active ability to stand. The available studies have not demonstrated high-grade evidence to support that a standing feature improves muscle function, skin integrity, bony health, or respiratory function in a clinically significant manner. Given these findings, the requested power standing feature is not medically necessary for treatment of this patient. All told, the requested power wheelchair accessories including standing feature and seat elevator are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.