Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Below the Knee Amputation

Treatment: Durable Medical Equipment (E2611 & K0001)

The insurer denied coverage for Durable Medical Equipment (E2611 & K0001)

The denial is upheld 

This case pertains to a patient and a request for a standard wheelchair.

The patient presented to establish care. The patient underwent a right below the knee amputation 6 months prior. The patient's stated weight is 125 pounds. The patient had a wound vac in place.

One month later, the patient presented for follow-up. The patient was feeling well. The patient no longer had a wound vac. The patient's weight was still 125 pounds. The right lower extremity amputation had a clean dressing, and the left lower extremity was without edema and a clean dressing over the foot. 

In follow-up, the patient presented via telehealth. The patient was doing well. The patient had been seen by their endocrinologist and cardiologist. The patient had left leg swelling without shortness of breath. The patient was attending physical therapy once a week and would like to attend more often. 

Two months later, the patient presented for a post-hospitalization follow-up. The patient had been admitted for five days for a hypertensive crisis. The patient's weight was recorded as 160 pounds. 

A letter was sent to the patient denying coverage of a standard wheelchair. They note a standard wheelchair was approved for the patient one year prior. They note the records indicate the current wheelchair will not support the patient's weight. The wheelchair requested is for patients who weigh less than 250 pounds. The request is for a second wheelchair for members who weigh less than 250 pounds. New York Medicaid limits patients to one wheelchair every three years.

The patient sent a letter of appeal. The patient noted that their original wheelchair request was never approved. Medicaid never paid anything. The patient includes documents that note the plan did not pay.

Medicaid funds and maintains one medically necessary manual mobility device to meet the member's medical needs whether primarily used in the home, community, or as a back-up to the primary. For these criteria to be met, the member must have an evaluation that was performed by a qualified practitioner who has specific training and/or experience in wheelchair evaluation and ordering. The practitioner must document, to the extent required by the coverage criteria for the specific wheeled mobility equipment, how the member's medical condition supports Medicaid reimbursement and determine whether the member's environment will support the use of these types of wheeled mobility equipment.

This case involves a patient with a history of a below the knee amputation. Documentation shows a claim was not filed within the required time period and the coverage for a standard wheelchair was denied. The denial letter notes the reason for the denial was that Medicaid only covers one wheelchair every three years. The documentation submitted clearly indicates that Medicaid did not reimburse the patient for the wheelchair the previous year. They also note there was no weight. Records indicate a weight of 160 pounds. 

The health care plan did act reasonably and with sound medical judgment and in the best interests of the patient. 

Durable Medical Equipment (E2611 & K0001) is considered appropriate for this patient. However, documentation needs to be submitted with a wheelchair assessment, measurements, home assessment with layout. Submission of home layout and wheelchair accessibility is needed for approval.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Durable Medical Equipment (E2611 & K0001) is not substantiated.