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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a whirlpool tub (HCPCS K1003).Spinal muscular atrophy (SMA) is a neuromuscular disease resulting in degeneration of alpha motor neurons in the anterior horn of the spinal cord and lower brainstem. SMA is clinically heterogeneous and has classically been categorized into 3 clinical subtypes based on age at onset and severity of symptoms, ranging from a most severe subtype (type 1) where patients rarely survive beyond infancy without respiratory support, to a least severe subtype (type 3) where there is ambulation at some point in life that is eventually lost due to disease progression. Kolb and Kissel state that many patients elude a precise subtype classification. The clinical features of SMA typically involve symmetric muscle weakness affecting the extremities, with proximal muscles affected more than distal muscles. There is also variable axial, intercostal and/or bulbar weakness. Cognition and sensory function are not directly affected by the disease. Treatment classically has largely been supportive in nature, to accommodate for muscular weakness and functional impairment. Interventions can include physical therapy, orthoses and mobility devices, such as wheelchairs, as well as surgery to address complications, such as scoliosis. More recently, with the elucidation of the genetic and molecular basis of SMA, disease-targeted therapy has been developed, studied and implemented, with promising and positive results.In this case, the records do list SMA as one of the patients diagnoses. The records, however, indicate that the patient has chronic pain, a functional disorder, and potentially undiagnosed and/or untreated mental health conditions that have been more clinically relevant to her symptomatology in recent years. Notably, there has been no documented muscular atrophy on physical examination to date in the available records. A whirlpool tub is not a part of routine management of any of the patients conditions, including SMA. Overall, a whirlpool tub is not expected to improve the patients health or function in any clinically significant manner. It is not clear whether the patient could tolerate time in a whirlpool tub, given her apparent hypersensitivities. Notably, she could not tolerate a tactile massage. Moreover, it is not evident that she could safely use this equipment, given some of her listed conditions, which include traumatic brain injury, seizure disorder, cognitive/memory impairment, panic attack, legal blindness, functional quadriparesis, numbness and peripheral neuropathy, all of which could potentially put her at risk for injury with use of this equipment. Therefore, a whirlpool tub is not medically necessary for the treatment of the 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.