Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) power wheelchair accessories including power seating system, center mount elevating leg/platform complete system and power standing system. Findings:  The physician reviewer found that Multiple sclerosis is an immune-mediated, demyelinating and neurodegenerative disease of the central nervous system that is a major cause of chronic neurological disability in young and middle-aged adults. Treatment involves controlling acute attacks, managing and preventing underlying disease progression, managing symptomatology, and managing the progressive functional impairments associated with the disease. Improvement of functional impairments may include the use of power mobility devices for accomplishing mobility-related activities of daily living (MRADLs) and instrumental activities of daily living (ADLs). In the present case, the patient has demonstrated progressive functional decline due to her multiple sclerosis, as she is no longer able to ambulate or use a manual wheelchair to accomplish her MRADLs and instrumental ADLs. She has been approved for a group 3 power wheelchair. This wheelchair has power tilt-in-space functionality to provide her a means of independent pressure relief. The available records do not document a clinical rationale for the requested power center mount leg elevation. Power leg elevation on a wheelchair is typically used to address leg edema or to prevent leg edema in persons at risk of this condition, e.g., due to cardiomyopathy. Leg elevation is a cornerstone of management in this clinical scenario. The examination that is documented in the records, however, showed no leg edema. An echocardiogram was recommended, but there are no documented results or indications that the study was completed. Based on the available records, the power center mount leg elevation feature is not medically necessary. Similarly, the requested power standing system is not a medically necessary accessory on a power wheelchair. There is a paucity of high-grade evidence to support that regular passive standing with use of a power standing feature equipped on a power wheelchair provides clinically significant benefits with respect to health or functional outcomes in the setting of neurological weakness due to multiple sclerosis or other conditions impairing the active ability to stand (Newman and Barker). This patient should be able to accomplish MRADLs in her power mobility device without the standing feature. If items are not accessible due to height, the appropriate accommodations should be made to her environment. Power standing does provide a user in a wheelchair with an ability to be more at even eye level with able-bodied persons who are in a standing position. However, persons do not have a medical need to be at or close or even eye level to interact. Thus, the requested power standing system is not medically necessary for this patient. Based on these findings, the requested DME power wheelchair accessories including power seating system, center mount elevating leg/platform complete system and power standing system are not medically necessary for this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.