Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder - Seizures.
Treatment: Durable Medical Equipment - Courtney Bed.
The health plan denied the requested Durable Medical Equipment - Courtney Bed as not medically necessary. 
The health plan's determination is overturned.

The patient is a male who has been diagnosed with medically intractable epilepsy due to Lennox Gastaut syndrome. Reports and letters from his treating physicians describe that the patient has bilateral cortical laminar heterotopia. His seizures remain uncontrolled despite anticonvulsant medications, the ketogenic diet, and a vagal nerve stimulator. He has mixed seizure types, including tonic and atonic "drop" seizures, and generalized tonic clonic seizures. His parents have a camera monitoring him for seizure activity at night. The patient has global developmental delay and a history of aspiration of food. He has a gastrostomy tube in situ. He wears a helmet for protection from head injury during seizures. His gait is unsteady, and he requires assistance and a gait trainer. The patient wakes up at night and also has nocturnal seizures.
The patient's parents and treating physicians are requesting an enclosed canopy bed. There is concern that he could become entrapped and asphyxiate if he has a seizure in a bed with protective side rails. The family has tried using a mattress on the floor, but he fell off of this hitting his head. He has also tried to get up and fell as a result of a "drop" seizure. Safety hazards have been removed from his bedroom, and a video monitoring system is in place. The family has an established bedtime routine for the patient.
The requested Courtney bed is padded to prevent injury and entrapment and has a soft mesh surround to prevent elopement. It is low, allowing the patient to independently get in and out of bed with supervision.
At issue is the medical necessity the requested health service/treatment of Durable Medical Equipment-Courtney bed.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Durable Medical Equipment-Courtney Bed is medically necessary for this patient.
The patient has medically intractable epilepsy (Lennox Gastaut syndrome) and global developmental delay as a result of his brain malformation, bilateral cortical laminar heterotopias. He has mixed seizures, including generalized tonic clonic seizures, and tonic and atonic "drop" seizures. The latter seizure type places him at high risk of injury should he fall during a nocturnal seizure. There is a risk of sustaining facial lacerations, dental trauma, and fractured limbs as a result of falls due to these seizure types. Uncontrolled nocturnal seizures also place him at risk of entrapment between a bed mattress and protective side rails during a seizure.
Sherburne et al [1] performed a "retrospective chart review of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period." The authors concluded that "Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety."
Bernal-Celestino et al [3] reviewed the incidence of falls in individuals with intellectual disability. The authors noted that "Falls are the second leading cause of accidental or unintentional injury deaths worldwide, also, falls generate severe disabilities, institutionalization and increase healthcare costs. People with intellectual disabilities fall over frequently." "The articles analyzed showed that age, history of seizures, gait and behavioral problems and environmental factors were the main risk factors for falling. Many fallers had suffered injuries."
Therefore, the requested health service/treatment of Durable Medical Equipment-Courtney Bed is medically necessary for this patient.