Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lumbosacral spina bifida
Treatment: Durable medical equipment - wheelchair and accessories
The insurer denied coverage for Durable medical equipment - wheelchair and accessories.
The denial is upheld.

This is a male patient with diagnoses that include lumbosacral spina bifida, peripheral polyneuropathy, and a history of wounds and osteomyelitis requiring the daily use of a manual wheelchair within the patient's home and at school for positioning, accessibility, mobility, and transport, and during periods of wound healing when required to maintain non-weight bearing status. Records state that it is projected that the patient will remain in his wheelchair for 16-18 hours per day when non-weight bearing for wound healing and requires the use of chair for long distances at home, school, and in the community due to lower extremity weakness, poor endurance, and diminished sensation. He has a low sacral level paraplegia with numbness. A specific Quickie 2 wheelchair is requested.
There is no indication that an alternative device (lightweight or ultra-lightweight wheelchair for examples) is incapable of meeting this patient's mobility and Mobility-related Activities of Daily Living (MRADL's) needs. This is a convenience item, and not in line with medical policy. The request as a whole, wheelchair and accessories is not medically necessary.

"The wheelchair (WC) is one of the most important examples of mobility-assistive equipment (MAE) available to patients with impaired mobility. Otherwise known as a "wheeled mobility device" (WMD), the WC has revolutionized the treatment of patients experiencing disability and has had a significant impact on those with serious functional restrictions. According to the National Institutes of Health, fifty-three million Americans lived with a disability in 2017. In 2019, this number rose to over sixty-one million Americans (or 25.7% of the population). Furthermore, 5.5% of the overall United States population used MAE in 2019 with WC use comprising 1.6%. WC prescription has the potential to significantly increase the quality of life for these individuals and allow increased participation in the community. The World Health Organization (WHO) has developed guidelines that highlight eight steps to standardize the process of wheelchair service delivery. These include (1) referral and appointment; (2) patient assessment; (3) WC prescription; (4) funding and purchase; (5) device installation and preparation; (6) device fitting; (7) patient instruction and training; and, (8) follow-up maintenance/repairs." (Owens, et al., 2022)

"Spina Bifida is a generalized term for the neurologic condition resulting from the failure of neural tube closure of varying degrees during fetal development. It can lead to significant neurologic dysfunction and can cause functional limitations in adulthood affecting the quality of life. Spina bifida is associated with several complications and sequelae involving various organ systems so it is important to diagnose early and take a multidisciplinary approach to prevent severe morbidity." (Brea, C.M., and Munakomi, S., 2022)      

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

The insurer's denial of coverage for durable medical equipment- wheelchair and accessories is upheld. Medical Necessity is not substantiated.