Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, Celiac disease, hypertension, hyperthyroidism, history of pulmonary embolism, autonomic dysfunction, chronic anticoagulation, failure to thrive, bowel and bladder incontinence, and elevated liver function tests

Treatment: Stair Lift

The insurer denied coverage for stair lift

The denial is overturned

 
A determination notice indicated the denial of an appeal request for a stair lift as the patient was noted to live in a private home with family, is able to make her needs known, has supportive family involved in the patient's care, has 13 stairs leading to the front of her home, requires assistance of 2 to ambulate up and down stairs, and reported no falls, emergency room (ER) visits or hospitalizations in the 90 days leading up to the assessment. It was also noted that the patient is able to ambulate with a walker with moderate assistance, and has transportation options available that can help the patient ambulate stairs. The patient was seen for a neurology consult visit. The physician stated that the patient had severe Parkinson's disease with continued progression and orthostatic hypotension. The treatment plan included discontinuation of her morning dose of Sinemet to assess for a decrease in morning sedation, continuation of Proamatine and Florinef, additional physical therapy, and a request for a stair life. An appeal letter indicated an appeal request for a stair lift as the patient is elderly with multiple diagnoses including Parkinson's disease, Celiac disease, hypertension, hyperthyroidism, history of pulmonary embolism, autonomic dysfunction, chronic anticoagulation, failure to thrive, bowel and bladder incontinence, and elevated liver function tests (LFTs). It was noted that the patient was wheelchair dependent with decreased ambulation, orthostatic hypotension, and functional weakness, and is unable to complete activities of daily living on her own. The patient's bedroom and bathroom are located on the second floor in her home, and the patient is unable to navigate the stairs without the assistance of 2 people to carry her up and down the stairs, which takes approximately 10-15 minutes. This review pertains to the denial of coverage for a stair lift.

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

Evidence based literature indicates home modifications that increase stair accessibility are of great significance to older adults who wish to age in place, as older adults are at increased risk of falls on stairs. Additional literature indicates home assessments and modest infrastructure improvements can significantly reduce falls in patients over the age of 65. The patient is noted to have a history of falls, weakness, and orthostatic hypotension. Additionally, the patient is wheelchair bound, and her bedroom and bathroom are located on the second floor of her home, requiring the assistance of 2 people to carry the patient up and down the stairs. As such, the stair lift is considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. 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 Stair Lift services is substantiated.