Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis.
Treatment:  Stair Lift.

The insurer denied the Stair Lift.  The denial was overturned.

This is a female who lives in a private home with her daughter.  The patient primarily lives in an area on the first floor of the house where she has her bedroom and a half bathroom (toilet and sink).  A walk-in shower with bench and hand held shower head is located on the second floor.  The patient has severe osteoarthritis of her knees (as per her orthopedist) and has substantial difficulty with stair climbing.  In order for the patient to continue having access to a shower alternative method to stair climbing was recommended by her orthopedist; i.e. a chair lift.  The daughter requested approval from the insurer which was denied.  An external appeal was requested.

The physician submitted a letter which includes the following: The patient has significant osteoarthritis of both knees, with difficulty ambulating and performing ADLs. She requires a stair lift for safety and stability.  Patient is followed by orthopedics and her severe osteoarthritis of her knees and has been treated with corticosteroid injections.  The patient elects not to pursue joint replacement.  She has difficulty with stairs to use the upstairs bathroom.  She is encouraged to remain mobile but not to overstress the knees with stair climbing.  It is medically necessary for the patient to have alternative to stairs.  Recommendation was given for stair lift.

Osteoarthritis (OA) is common in the elderly and is a frequently a primary or partial cause of functional impairment.  As it progresses in severity OA of the knee can affect many daily activities, including IADLs that require standing, walking, bending (e.g. housework, meal preparation, stairs, shopping).  The patient requires maximal assistance or total dependence for all these IADLs, and it is likely that OA of her knees is a significant contributing factor.  For ADLs, knee pain adversely affects bathing, dressing lower body, transfers (to and from toilet, chair, bed), walking.  The patient requires varying levels of assistance for all these ADLs.  Knee OA can be treated with various modalities including physical therapy/exercise programs; medications (oral, topical, intra-articular injection); surgery, including joint replacement.  The latter is typically an option when non-surgical treatment has failed to provide a satisfactory outcome for the patient's symptoms and functional status. 

The patient has frequent incontinence.  Incontinence care throughout the day and night with cleaning/hygiene on the toilet or in the bed is necessary and provides adequate care at the time when incontinence occurs; but a person who has frequent incontinence should have a shower or bath on a regular basis to provide satisfactory cleaning and hygiene.  As defined by the Social Services Law, the patient has a medical condition (severe osteoarthritis of both knees) that interferes with her capacity for normal activity (showering) in her home.  Environmental modification (which includes lifts in the MLTC policy) indicates that the adaptation must be identified as necessary to enable the patient to function with greater independence in the home, or to substitute for human assistance that would otherwise be authorized.  

It is medically necessary for the patient to have a stair lift in her home as a result of her severe osteoarthritis of both knees.  Access to the upper floor of her home is needed due to lack of shower or bath on the first floor of her home in order to maintain her ability to have proper bathing/hygiene on a regular basis in a shower, especially with consideration of her frequent incontinence. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  A chair lift is medically necessary.

The carrier's denial of coverage for Stair Lift is overturned.  The medical necessity is substantiated.