Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Charcot-Marie-Tooth Disease

Treatment: Durable Medical Equipment

The insurer denied coverage for Durable Medical Equipment

The denial is overturned

The patient is a child with a genetic disorder caused by IGHMPP2 (immunoglobulin mu DNA binding protein 2), a gene mutation presented with Charcot-Marie-Tooth Disease type 2s, restrictive lung disease, neuromuscular (NM) scoliosis, status post spinal instrumentation with magic rod placement. The patient was referred to seating and mobility assessment for durable medical equipment (DME) needs. The patient presents with generalized muscle atrophy in bilateral upper extremities and bilateral extremities with impaired coordination secondary to weakness. The patient has decreased upper extremity passive range of motion (PROM):  leg length discrepancy with right leg being shorter than the left and right thoracolumbar (TL) scoliosis with pelvic obliquity to the left resulting asymmetrical upright sitting position. The patient has impaired posture control and requires external support in a symmetrical, resting position. The patient requires assistance for performing transfers and can walk with assistance of posterior walker with hip guides/supports.  The patient has a Drive transport wheelchair that does not have an external support that the patient requires to provide in the upright sitting position. In addition there is no cushion on the seat of the transport wheelchair which could potentially result in skin breakdown. The request is for quickie Q300 mini power wheelchair with tilt with space power wheelchair. It was also noted that the patient has been doing physical therapy for safety in the power chair and has demonstrated the ability independently operate the right sided joystick and maneuver. The patient also demonstrated their ability to maneuver objective doors and around corners given age-appropriate supervision. The intended use of the device is primarily for daily mobility with accessible environments. 

Based on the information provided, the patient presents with generalized muscle atrophy in bilateral upper extremities and bilateral extremities with impaired coordination secondary to weakness. The patient has impaired posture control and requires external support in a symmetrical, resting position. The patient has the mental and physical ability to safely operate the powered tilt and joystick, and he has demonstrated enthusiasm and willingness to use the power device. 

The patient currently uses a drive transport wheelchair that limits their independence of mobility and current the device no longer supports the patient's spinal deformity and upper extremity and lower extremities for re-positioning. 

Per the cited references, while the needs of many individuals with disabilities can be satisfied with traditional manual wheelchairs, a segment of the disabled community finds that it is difficult or impossible to use wheelchairs independently. The patient has had a trial of a power wheelchair in therapy and this year during summer school, which has allowed them to experience mobility independence. In addition to promoting mobility independence, this device will provide greater support for spinal alignment; upper extremities support to functionally operate the joystick and tilt mechanism for support of the lower extremities. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Durable Medical Equipment is substantiated.