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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with cerebral palsy. The patient was noted to require assistance for all activities of daily living and required two-person assistance for transferring. The provider noted the patient had a previous fall that resulted in severe brain injury requiring brain surgery. The provider noted the patient is unable to reach items in the classroom and at home due to his inability to stand unassisted. The patient has been treated with physical therapy and uses a manual wheelchair. It was noted the patient ambulates short distances with a reverse Kaye walker with supervision to contact guard assistance. The patient uses hip-knee-ankle-foot-orthosis and ankle foot orthosis. The patients parent has requested authorization and coverage for a Dynamic Rifton Pacer Gait Trainer. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a Dynamic Rifton Pacer Gait Trainer is medically necessary for the treatment of this patient. Researchers reported, The relation between what an ambulatory child with cerebral palsy is able to perform in a clinical setting and their participation in life is significantly mediated by what they actually do motorically in day-to-day life. Results suggest that interventions focusing on improving what they actually do every day, regardless of their capacity to perform (what they can do when tested), may positively influence participation. The authors also noted, Children with cerebral palsy (CP) had significantly lower physical activity performance, as measured by the School Function Assessment. Children with CP and lower activity performance participated significantly less often than their typically developing peers in daily school activities (i.e., playground games and moving to other areas of the school). Motor function has also been shown to be predictive of less participation in mobility, education, and social relations for children with CP. In this case, the patient has had a previous fall that resulted in brain trauma. Standing and moving in a safe and appropriately positioned and supported manner using a custom fitted dynamic gait trainer will help improve independence, daily functioning, performance and participation, leading to improved quality of life for the patient. The medical evidence supports the requested equipment in this clinical setting. Therefore, a Dynamic Rifton Pacer Gait Trainer is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine 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.