Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis (MS)
Treatment: Power Wheelchair (PWC), codes K0739 x32, K0108 x7, E2378, E2363 x2, E2376, E2311, E2620, E0955, and E1028 x2 repairs
The insurer denied coverage for power wheelchair (PWC), codes K0739 x32, K0108 x7, E2378, E2363 x2, E2376, E2311, E2620, E0955, and E1028 x2 repairs
The denial is overturned.

The patient is an adult female who presented for appointment for multiple sclerosis (MS). She was last seen and had cognitively improved, though motorically worse, felt diffusely atrophied, and was a little fatalistic. The patient then developed renal failure, in the setting of having had numerous severe urinary tract infections with sepsis and treatments with various antibiotics. She felt very fatigued on the last visit. Since the last hospitalization she had pain in the shoulder. Now she can be confused about the time of day and with paranoia. She is not a candidate for kidney transplant due to susceptibility to infection. Physical examination reveals she is confused, thinks husband and others are conspiring against her. No movement in the arms or legs. Reduced passive tone in the legs. The diagnosis was MS and lethargy. The plan was for medication and blood work.

Based on the information provided, the policy coverage indications for replacement state that replacement of durable medical equipment (DME) should be indicated for DME whose reasonable useful life span has expired or has become irreparable. 

As stated in the United Wheelchair Coverage Policy:  Indications for Coverage: Wheelchair seating is proven and Medically Necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual Medicare: Durable Medical Equipment, Wheelchair Seating. Repair, Replacement, and Upgrade: Replacement of DME is for the same or similar type of equipment which is beyond its reasonable useful life span and has become irreparable.

Upgrade: The physician provides documentation that the condition of the member changes (e.g., impaired function necessitates an upgrade to an electric wheelchair from a manual one).

General Criteria: Routine wear on the equipment renders it non-functional and the member still requires the equipment.

- Vendors/manufacturers are responsible for repairs, replacements, and maintenance for rented equipment and for purchased equipment covered by warranty
- Coverage includes DME obtained in a physician's office, DME vendor, or any other provider authorized to provide/dispense

DME: Unless otherwise stated, DME has a Reasonable Useful Lifetime (RUL) of 5 years. 

Note: A new prescription isn't needed if the needs of the patient are the same.

Equipment Upgrades: A change in the member's medical condition and equipment needs requires the same documentation as a new request. Equipment upgrades are equivalent to a new service" (4)      

Based on the documentation provided, there is no evidence that the wheelchair is irreparable. Therefore, it seems reasonable that the patient should have her wheelchair repaired.

"The progressive disability course of Multiple Sclerosis (MS) is leading to significant individual and societal burdens. As MS typically is diagnosed at an early age, most people with MS person with multiple sclerosis (PwMS) will likely experience disability across different areas of functioning for decades. Therefore, understanding the course across a wide spectrum of disability is required to prioritize and optimize health services for PwMS." (Conradsson, D. et al. 2018)                                                       

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for repairs for power wheelchair (PWC), codes K0739 x32, K0108 x7, E2378, E2363 x2, E2376, E2311, E2620, E0955, and E1028 x2 is overturned. Medical Necessity is substantiated.