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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with necrotizing autoimmune myopathy, polymyositis with quadriparesis, and restrictive lung mechanics due to neuromuscular disease. The patient was noted to have a blanchable red area on her right buttocks that was noted to be associated with moisture. It was noted the patient received skilled physical therapy, with no progress noted. Physical examination findings included severe weakness of all four extremities in both proximal and distal muscle groups, and poor head and trunk control. She was cognitively intact. The patient requires two people for mobility assistance. The patient has requested authorization and coverage for occupational therapy and physical therapy services and a Hill-Rom Envella micro bead sand bed. The Health Plan denied the requests and reported the requested services and equipment are not medically necessary for the treatment of this patient. At issue in this case is whether occupational therapy and physical therapy services and a Hill-Rom Envella micro bead sand bed are medically necessary for the treatment of the patients medical condition. McInnes and colleagues reported, Pressure ulcers are more likely to occur in those who are seriously ill; neurologically compromised (e.g. individuals with spinal cord injuries), have impaired mobility, or who are immobile (including those wearing a prosthesis, body brace or plaster cast). Other risk factors include impaired nutrition, obesity, poor posture, which puts extra pressure on bony prominences, or using equipment that does not provide appropriate pressure relief, such as seating or beds. The authors also noted, Pressure-relieving cushions, beds and mattresses either mold around the shape of the patient to distribute the patients weight over a larger contact area (constant low-pressure (CLP) devices); or vary the pressure beneath the patient mechanically, thus reducing the duration of the applied pressure. These devices fit, or mold, around the body so that the pressure is dispersed over a large area and are mainly classified as being of a lower technological specification (i.e.low-tech). In this case, the patient is at a high risk for skin pressure ulcers due to her multiple medical diagnoses. The medical evidence supports the requested equipment in this clinical setting. Therefore, a Hill-Rom Envella micro bead sand bed is medically necessary for the treatment of this patient. The patient has failed a trial of physical therapy and could not meet her goals, which were appropriate for her condition. Her endurance, posture, strength, motor, and balance impairments limit her wheelchair sitting tolerance. She remains dependent for bed mobility, weight shifts and all transfers. She does not qualify for further physical or occupational therapy intervention. The medical evidence does not support occupational therapy or physical therapy services in this clinical setting. Therefore, occupational therapy and physical therapy services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.