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 motor scooter.The 25-foot walk test has been recognized as an ideal measure for objective characterization of walking dysfunction for persons with multiple sclerosis. In a recent, large quantitative synthesis review, mean 25-foot walk test scores were reported of 4.30.8 seconds for controls without multiple sclerosis (MS), 6.73.1 seconds for ambulatory persons with MS overall, 5.21.1 seconds for persons with mild MS, and 10.68.3 seconds for persons with moderate to severe MS. Slower gait speeds on this test have been associated functionally with clinically meaningful outcomes such as greater incapacity status and higher frequency of falls. A clinically meaningful benchmark in MS of 8 or more seconds has been reported in the literature to be associated with the need for a walker and inability to perform instrumental activities of daily living.In the present case, the patient has had a gradual, overall functional decline associated with her MS over many years but has managed to retain her ability to ambulate to some functional extent with a walker. The records indicate that her gait speed when walking using a walker has actually improved, from a 15.2 second 25-foot walk test to a 10 to 12 second walk test. This is a clinically meaningful improvement. The records also indicate that the patient has improved with her compliance using a walker. Her treating neurologist recommended further walking, exercise and therapy. There were no recommendations at that time for a power mobility device.The patient, nevertheless, has sufficient impairments in her mobility such that a walker would not be expected to be able to meet all of her instrumental activities of daily living needs, including access to the community. Previously, she had been determined to be an appropriate candidate for use of a group 2 power wheelchair, which would appear to be one potential appropriate device so that she can safely, effectively and efficiently meet her instrumental activities of daily living and community-based mobility needs. Another potential mobility aid could be a manual wheelchair, which would also have the advantage of promoting a measure of physical activity that would be beneficial to the patients health, albeit at the cost of speed and efficiency. A manual wheelchair, however, would be less bulky and provide more precise maneuverability in comparison to any powered mobility device, which can be helpful in many indoor situations.The records, on the other hand, do not indicate that the patient has ever been determined by any treating or evaluating health care professional to be an appropriate candidate for a powered scooter, which requires sufficient upper limb strength and endurance to operate safely, as well as truncal balance, strength and endurance. Under these circumstances, the requested motor scooter is not medically necessary for the patient to perform one or more mobility related Activities of Daily Living or Instrumental Activities of Daily Living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested durable medical equipment is not medically necessary for the patient to perform one or more mobility related Activities of Daily Living or Instrumental Activities of Daily Living in or out of the home, including access to the community. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular medicine, 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.