Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal cord injury
Treatment: Durable Medical Equipment (DME) (smart drive power assist for manual wheelchair)
The insurer denied the Durable Medical Equipment (DME) (smart drive power assist for manual wheelchair)
The denial is upheld. 

The patient is a male. He has a history of a T9 (ninth thoracic spine vertebra) level spinal cord injury due to a gunshot wound several years prior.  There is residual paraplegia with neurogenic bladder and bowels.  He self-catheterizes his bladder.  He is independent with his bowel care via colostomy.  He had a prior sacral pressure ulcer for which he underwent skin flap surgery with resolution.  He did, more recently, develop a stage 2 pressure injury in the right buttock area.  He has occasional low back pain and takes pregabalin, which is reported to be adequate for addressing this pain.  He smokes marijuana daily.

Functionally, the patient lives alone in an elevator-accessible apartment.  He is non-ambulatory.  He uses a manual wheelchair for indoor mobility, which he can self-propel independently.  His shoulders hurt when he goes long distances.  He is independent with transfers in his home.  He requires assistance for transfers into and out of a van.  He is independent with bathing, dressing and meal preparation.  He receives home attendant services regularly but intermittently for housekeeping and shopping assistance.  He also has multiple family and social supports.  He receives medical transportation services.  He is not working or seeking employment.

The patient was reported to be in possession of a power wheelchair, the current disposition of which is not addressed in the available records.  There is also mention of a "scooter" in his recent records, which is not further described or discussed.

A Smart Drive rear-mounted power assist module for the patient's manual wheelchair has been recommended.  His mother states that it will help him move more efficiently, attend classes, shop in the grocery, help him go up hills and improve his overall emotional well-being.  His family physician notes that the patient "independently performs [activities of daily living]," but his "manual wheelchair is inadequate for this."

No, the smart drive power assist for manual wheelchair is not medically necessary.

The records do not establish that the patient requires the proposed service to perform his activities of daily living.  The patient has no documented upper body impairments, and he is independent with his activities of daily living and basic household mobility at a manual wheelchair level.

There are no indications that the patient has a regular need for mobility in the community.  He has a home attendant and social supports for his shopping needs.  He receives medical transportation services.  He is not documented to be attending any school where he needs to navigate a campus.  He is not documented to be working at a site where prolonged bouts of self-propulsion of a manual wheelchair are required.  There is also documentation in the records that suggest that he may possess a powered mobility device already.

The records do not establish that the patient requires the service to accomplish any tasks that are medically necessary that he cannot already perform independently in a manual wheelchair without the service.  The patient does report shoulder pain with longer distance manual wheelchair propulsion, but this is not discussed further in detail.  Some discomfort is not unexpected with any prolonged physical activity.  It is not clear, however, whether there are biomechanical problems that need to be addressed that may be responsible for his shoulder symptoms, especially given that he is reporting these symptoms despite only having used a manual wheelchair for a few years.  There are no indications in the records that his seating posture, stroke/propulsion techniques, wheelchair fit, and general fitness and recovery strategies have been examined and addressed as needed to optimize mechanical efficiency and mitigate risk of injury.  Persons can continue to have persistent symptoms and develop injuries with bad fit, technique and biomechanics despite the use of accessories such as a rear mounted power assist module for a manual wheelchair.