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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an electric wheelchair (with a Group 4 base which allow standing) for treatment of the enrollees spastic quadriplegic cerebral palsy. Findings:  The physician reviewer found that the published medical literature notes that targeted exercises can enhance bone strength at loaded sites in children, but the effect on adults remains unclear. The consensus regarding bone health in paralyzed or immobilized patients is that there are numerous factors that contribute to accelerated diminution of bone health including the denervation of sclerotomes, humoral factors, vitamin D deficiency, and the lack of pulling activity from muscles. The published medical literature with respect to interventions such as standing frames or standing wheelchairs to address bone health issues in the setting of severe neurological disorders such as cerebral palsy is sparse and consists of anecdotal reports and preliminary studies with disparate and inconclusive results. There is currently a lack of high-grade evidence to support that use of this type of device reduces osteoporosis or reduces fracture risk to a clinically significant degree in the setting of severe neurological disorders affecting the central nervous system. There is also a paucity of high-grade data to support that use of the device provides other clinically significant benefits with respect to health or functional outcomes in the setting of these types of conditions.  The patient in this case is at elevated risk for pressure ulcers due to his condition, but the standing feature on his wheelchair would not be expected to significantly improve his overall risk profile for pressure ulcers. The use of this feature may potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. He would remain at risk for pressure sores with or without the standing feature until the underlying cause for these stage 2 sores is addressed, which is not a lack of standing. These type of sores have the potential to develop in less than one hour of sitting. In addition, the requested device would be expected to reduce the accessibility of the wheelchair by introducing additional size and weight to the wheelchair and increasing its turning radius, while also increasing the risk of wheelchair breakdown. Wheelchair breakdown has increased significantly as wheelchairs are being prescribed laden with additional componentry, at the sacrifice of simplicity, efficiency and durability. For these reasons, the requested electric wheelchair (with a Group 4 base which allow standing) is not supported as medically necessary for treatment of this patients medical condition. 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.