Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tetraplegia

Treatment functional neuromuscular stimulator

The insurer denied coverage for a functional neuromuscular stimulator for 

The denial is upheld

According to the documentation submitted, this is the case of a male with a history of cervical level 6/7 (C [cervical] 6/7) tetraplegia as the result of a motor vehicle accident (MVA). He presented to the Physical Therapist's (PT) office for continued treatment of paralysis. The PT plan of care included individual treatment, aquatic therapy, active range of motion (AROM), passive range of motion (PROM), balance training, bed mobility, transfer, strengthening, positioning, endurance activities, breathing techniques, orthotic training/management, seating assessment/modification, modalities, pain management, sensory re-education, maintaining fall precautions, and patient/family education. They recommended seeing the patient twice a week for 6-8 sessions for functional electrical stimulation (FES) therapy.  

Exercise effects include changes or modifications in cardiovascular or vascular responses, metabolism, and muscle parameters. Health related benefits include measures of cardiac function and indicators of cardiac disease, metabolic function and indicators of diabetes or other metabolic disease or instability. 

In this particular case, there were several instances when the patient showed poor compliance in home exercises or lack of compliance with therapist's recommendations. In the progress note  that the patient participated in acute rehab and outpatient rehab shortly after the accident. However, he has not participated in any consistent formal therapy since then.

His past medical history showed that he had a history of lower extremity deep vein thrombosis (DVT) and sacral decubitus. SCI patients usually are prone to these issues due to immobilization or lack of compliance with positioning or participation in a home exercise program.

Bone density test was advised by the therapist prior to the patient's returning back to upright positioning. The patient took the initiative to increase tolerance for the standing chair without Dexa scan. This was against the advice of his treating physical therapist.

The patient progress notes that the patient had no initiative at home. He had not used his standing chair in quite some time and had been inconsistent with the home exercise program.

The therapist notes that the patient was previously seen for 35 visits. He abruptly discontinued himself from therapy during that time.

The notes cited above indicate the patient's lack of compliance in home therapies and therefore may not be a good candidate for the use of FES cycling at home.

There are many challenges in a review of the literature on the health benefits of FES cycling. The methods used in the studies namely the training paradigms and the outcome measures differ making it difficult to determine which training approach would be best for any particular person with SCI. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

Functional neuromuscular stimulator is not considered medically necessary for this patient. 

This decision is based on clinical standards of the plan, the 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 societies, boards, and associations. 

The insurer's denial of coverage for a functional neuromuscular stimulator is upheld. Medical necessity is not substantiated.