Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dandy Walker syndrome and hypotonia
Treatment: Bath chair (E1399 x 2)
The insurer denied coverage for bath chair (E1399 x 2)
The denial is overturned
 
The patient is a toddler with a diagnosis of Dandy Walker syndrome and hypotonia. He has very poor muscle tone and balance, and rarely rolls over. He has limited functional mobility, and requires maximum assistance and support to participate in activities, as he does not have purposeful active movement of head, trunk, and extremities. The request is for an Otto bath chair, and Otto tub stand.

A bath chair (E1399 x 2) considered medically necessary for this patient. The child has Dandy Walker syndrome and hypotonia. He has very poor muscle tone and balance, and rarely rolls over. He has limited functional mobility, and requires maximum assistance and support to participate in activities, as he does not have purposeful active movement of head, trunk, and extremities. The child is not able to safely maintain his own position, and lying in a tub or shower would not allow the child to be safe during bathing, and would be an increased risk for ingestion of water. The bath chair is appropriate and gives more safety during bathing.

"Self-care activities for infants and small children are performed by their caregivers/parents. Gradual independence is achieved in these activities by children, based on various intrinsic and extrinsic factors, including intellectual, personal and hand function development. Despite sufficient gross motor, intellectual and manual abilities, some children are unable to achieve independence in self-care activities." (Kim et al., 2017).

"Global evidence-based guidelines for the treatment and rehabilitation of children with congenital anomalies are also needed to strengthen the quality of service provision. Data on coverage and access to rehabilitation services for children with congenital anomalies, as well as other social determinants of health and equity measures, need to be included at local levels of health systems to ensure performance management for equity and to inform rehabilitation and assistive technology provision. Integrating these data with routine health information systems and ensuring the data are made accessible and actionable for national and subnational health leadership is essential to strengthen rehabilitation services from birth." (Smythe et al., 2022).

"Although there are multiple approaches to implementing the medical home, they all revolve around five core attributes. Care should be (1) patient- and family-centered, (2) comprehensive, (3) coordinated, (4) accessible, and (5) committed to quality and safety. Patient-centered care recognizes that patients are individual and unique, "known as persons in the context of their own social worlds, listened to, informed, respected, and involved in their care-and their wishes are honored (but not mindlessly enacted) during their health care journey". For pediatric patients, the concept of "patient-centeredness" includes both patient- and family-centered care, as the family is the child's primary source of strength and support. Families are resources for information concerning the child's well-being, and need to be treated as integral partners of the care team. Pediatricians who support the interactional relationship between the child's health and the family structure observe more adherence to the steps outlined in the patient's care plan and greater patient and family satisfaction with the health care received, among other benefits." (National Academies of Sciences et al., 2018).          

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a bath chair (E1399 x 2) is substantiated.