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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair with group 4 base. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The patients home is reported to have a ramp that is described as steep. It is reported that this ramp is needed to negotiate entry/egress to the bedroom. The ramp slope, incline, or grade is not documented. The type of ramp surface, construction and stability is not documented. A group 4 power wheelchair to be used to attempt to negotiate a ramp in the home that is reported to be unsafe for negotiation with a group 3 power wheelchair is not medically necessary.  While a trial may have ostensibly shown that the group 4 wheelchair that was trialed may have negotiated the ramp safely in the view of the patient, the wheelchair vendor, and/or other individuals who may have attended the trial in the home, this is inherently unsafe. Small alterations in wheel-ramp surface interface traction due to tire wear and surface debris could result in slip and catastrophic tipping accidents. Even small changes in slipperiness can significantly increase the risk of accidents. Small changes in center of gravity could also result in tipping accidents. Slopes, notably, are a frequent setting for wheelchair-related accidents. Therefore, there are various standards for ramps. A 1:12 slope is a recommended maximum, and less steep slopes are generally considered more appropriate. For power wheelchairs, ramps of 1:5.6 slope have been shown to be able to be safely negotiated. The notation that the current power wheelchair or that the trialed group 3 power wheelchairs could not safely negotiate the ramp in question in this patients home suggests that this ramp is particularly steep. The appropriate intervention to address a steep ramp is to replace it with a safer ramp with a lower slope. A group 3 power wheelchair should be able to negotiate such a ramp. A group 4 power wheelchair aimed at negotiating an unsafely steep ramp on a regular basis is not medically necessary and is not safe.  As the patients current power wheelchair no longer fits and has a broken frame, a replacement group 3 power wheelchair would be appropriate and medically necessary.  A group 3 power wheelchair would meet the patients needs with respect to mobility-related activities of daily living.  A group 4 power wheelchair is not needed to meet the patients medical needs. Therefore, the requested power wheelchair with group 4 base is not medically necessary for the treatment of 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.