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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for power wheelchair accessories, power standing, and seat lift for the approved Group 3 power wheelchair. There is currently a paucity of high-grade evidence to support that regular 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 paraplegia or other neurological conditions impairing the ability to stand. Moreover, there is a lack of evidence to support claims that this type of feature improves pulmonary function, vascular circulation, bowel or bladder function, muscle function, skin integrity, bony health, or provides other health benefits in patients who are otherwise generally poorly mobile using their own body power. This patient 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 standing feature would potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. In addition, there is inadequate data demonstrating that the standing feature would obviate the need for anticoagulation. With respect to autonomic dysreflexia and hemodynamic issues, power standing functionality would not add any significant clinical benefit over position changes afforded by power tilt-in-space and recline. With respect to bone health, the published medical literature notes that targeted exercises can significantly enhance bone strength at loaded sites in children, but the effect on otherwise healthy adults remains unclear. Furthermore, there is limited evidence to support that use of this type of device reduces osteoporosis or reduces fracture risk to a clinically significant degree. The records indicate that the patient requires moderate assistance of another person for transfers. There is no documentation in the available records that he is able to perform safe, independent transfers by utilizing the downhill gradient afforded by power seat elevation. Power seat elevation would be a convenience for a caregiver who would otherwise be assisting the patients transfers a little more physically than usual. Overall, the requested power standing and power seat elevation features for an approved power wheelchair are unproven with respect to health issues. Thus, the requested power wheelchair accessories, power standing, and seat lift for the approved Group 3 power wheelchair are not 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.