Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. In older patients with spinal cord injury, long-term medical complications can result in reduced community participation and quality of life as well as frequent hospitalizations. Some studies have reported that FES interventions with hand and leg cycling systems can be effective in helping to prevent secondary health conditions in patients with incomplete injuries, improve conditioning and fitness levels of patients, and increase patients participation in the community. The current literature provides sufficient evidence on the benefits of RT300 FES therapy system use when compared to standard, traditional therapy modalities alone, in achieving better outcomes with strengthening, reduced spasticity, and improved quality of life (van der Woude, et al.; Hitzig, et al.). Based on the documentation provided for review, this patients quadriplegia meets the requirements for treatment with the RT300 FES therapy system. The indications for the RT300 FES therapy for this patient include prevention of muscle disuse atrophy, improving blood circulation, maintaining or increasing range of motion, and prevention of contractures. This patients reported functional status, medical history with secondary complications of the spinal cord injury, prognosis of his injury, and neurological level of involvement support the use of the RT300 FES system. The provider noted that the patient has shown functional improvement with use of the RT300 FES thus far. The goal of the rehabilitation treatment plan for this patient is to maintain mental and physical health, improve quality of life, and prevent further deterioration of function and health with use of the RT300 FES therapy system. Therefore, the FES therapy system (RT300 Leg, Arm, Core) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the FES therapy system (RT300 Leg, Arm, Core) was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the device at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts 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.