Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain Stem Stroke, Hemiplegia
Treatment: Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
The insurer denied the request for the coverage of a Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds.
The health plan's determination is upheld.

The patient is a male with hemiplegia following brain stem stroke several years ago. The patient was prescribed and owned a manual wheelchair and a power wheelchair. The power wheelchair broke. Approval of repairs to the power wheelchair that the patient owned, were approved and parts were ordered. The parts were received and the repairs were completed. The patient was using a manual wheelchair while the power wheelchair was being repaired. The patient's spouse purchased a power wheelchair as the manual wheelchair was not meeting the patient's needs and the patient was not able to use the restroom with a manual wheelchair while the wife was at work. The patient's wife purchased a foldable/portable power wheelchair and is requesting reimbursement for the foldable/portable power wheelchair that was purchased while the primary chair was being repaired. The patient's wife was unable to rent a power wheelchair.

The requested health service/treatment of a Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds is not medically necessary. A wheelchair evaluation was not included in the medical records provided. An Assistive Technology Professional needs to provide the wheelchair. There is no documentation to indicate that it was less expensive to purchase a new power wheelchair when compared to repairing the existing power wheelchair that the patient already owned. There is no information about the type of repairs necessary for the power wheelchair that the patient already owned and the cost of these repairs, including the detailed cost of parts and labor. There is no documentation in the medical records provided to indicate that the second power wheelchair is necessary to meet the basic health needs of this patient or that the second power wheelchair is correct for the diagnosis of brain stem stroke. There is no evidence that the second power wheelchair: is not primarily for the comfort and convenience of the patient, the patient's family, or the patient's provider. There is no evidence that the second power wheelchair purchased while the first power wheelchair was being repaired is the least intensive and most appropriate setting for this service, since there is no documentation concerning the total cost, including parts and labor to repair the first power wheelchair. Without information concerning costs of parts and labor, one cannot determine whether it is more cost effective to repair or replace the first power wheelchair. There are many options for caregiving while a power wheelchair is under repair such as using the manual wheelchair that the patient owned and providing caregiver assistance while waiting for repairs. The health plan covers repairs and necessary maintenance of DME (Durable Medical Equipment). Replacement of DME is not covered when the existing equipment is still functional. The purchase of the second power wheelchair is not considered medically necessary and not considered the standard of care in United States at this time.

The health plan's determination of medical necessity is upheld in whole.