Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, hypertension, lower extremity lymphedema, diabetes mellitus, peripheral vascular disease.

Treatment environmental modification for the installation of indoor and outdoor ramps.

The insurer denied coverage for environmental modification for the installation of indoor and outdoor ramps.

The denial is overturned

This is a morbidly obese patient with multiple medical problems including hypertension, lower extremity lymphedema, diabetes mellitus, peripheral vascular disease and a right foot ulcer with gangrene.  She is non-ambulatory and uses a motorized wheelchair for mobility.  Under review is the medical necessity of requested environmental modification for the installation of indoor and outdoor ramps.

The insurer improperly cited the environmental modification criteria, "necessary to support the health, welfare and safety of the patient" and "necessary for and directly related to the patient's ability to remain safely in the home or community" as well as "there are no other options to safely and effectively meet the member's needs, as defined by the plan," to support the denial of the requested environmental modification for the installation of indoor and outdoor ramps.  However, the patient's lack of proper home accessibility is a significant safety issue.  The patient's functional ability is severely impaired.  According to the Uniform Assessment System (UAS) report, the patient requires extensive to maximal assistance for activities of daily living including bathing, personal hygiene, dressing and toilet transfer/use.   She is bed bound, non-weight bearing on the right lower extremity and non-ambulatory.  The patient's uses a motorized wheelchair for mobility.

The medical records document her multiple toe amputations/ulcers and IV (intravenous) antibiotic treatment for right lower extremity gangrene.  She has severe peripheral vascular disease; her functional mobility is likely to further deteriorate (with or without the benefit of home occupational/physical therapy) and a more proximal lower extremity amputation is a likely clinical outcome.   The requested environmental modification for the installation of indoor and outdoor ramps provides a lifeline for adaptive home ingress and egress.  Home ramp instillation is medically necessary for access to clinical services and the community.  This physician also agrees, the insurer does not provide any other particular solution for the medically necessary safe access and egress to and from the patient's home. 

The healthcare plan acted did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested environmental modification for the installation of indoor and outdoor ramps is medically necessary.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the environmental modification for the installation of indoor and outdoor ramps is reversed. Medical Necessity is substantiated.