Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis of bilateral knees, epilepsy, hypertension, anxiety and depressive disorder.
Treatment: Social and Environmental Supports: Ramp, Pre-service.
The insurer denied the Social and Environmental Supports: Ramp, Pre-service.
The denial is overturned. 

This is a female with medical conditions including dementia, osteoarthritis of bilateral knees, epilepsy, hypertension, anxiety and depressive disorder.  She lives with her daughter in a private home.  She is appealing denial of Social and Environmental Supports Ramp.

The member has been provided with a Stair Lift that was installed a year ago.  She receives Ambulette services with two person assist to go out of the front door.  The daughter reports that the member is in a wheelchair because her knees buckle.  The ramp is requested to exit the home with wheelchair. Recommends ramp for safe exit of her home.  UAS (uniform assessment system) evaluation completed notes there are four steps to a flat area, three steps to another flat area, then four steps to driveway.  The member requires two person assistance to get down the steps.

The member's cognitive status is severely impaired.  Functional status shows total dependence with meal preparation, housework, managing finances and medication, and shopping; maximal assistance with phone use, stairs, transportation, bathing, dressing, and toilet use; extensive assistance with personal hygiene, walking locomotion, toilet transfer and bed mobility; and limited assistance with eating.  There have been no falls in the past 90 days.  She uses a walker in the home.  Compared to UAS evaluation completed two years ago, there has been a decline in the member's functional status.

An appeal letter from the provider states the member is unable to ambulate up and down the stairs due to severe arthritis.  A letter from the PT (physical therapist) states the member is homebound and receiving PT (physical therapy) and is unable to tolerate performing elevation.

Yes. The proposed treatment is medically necessary.
The requested ramp is consistent with standard of care.

This member has severe bilateral knee osteoarthritis that has made her wheelchair dependent.  She requires 2 person assistance when exiting home due decreased ambulation skills and is unable to climb stairs.  It is noted that the member has Ambulette services.  However, these services are indicated for medical transportation and do not provide support should the member need or wish to leave her home for non-medical reasons.  The member is requesting a ramp so that she can enter/exit her home in her wheelchair.  Per The Social Services Law, standard coverage includes coverage for medically necessary supplies which are necessary to prevent, diagnose, correct or cure conditions that interfere with a person's capacity for normal activity or threaten some significant handicap.  This member is handicapped due to bilateral knee osteoarthritis.  As a result, she is unable to climb/descend stairs and is wheelchair dependent.  The requested ramp is medically necessary for this member to perform a normal activity of entering/exiting her home.