Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spastic diplegia, septo-optic dysplasia, hydrocephalus, and a ventriculoperitoneal (VP) shunt.
Treatment wheelchair and accessories.
The insurer denied coverage for wheelchair and accessories.
The denial is overturned.

The patient has spastic diplegia, septo-optic dysplasia, hydrocephalus, and a ventriculoperitoneal (VP) shunt.  The patient was evaluated for the stroller.  The cricket supportive stroller was requested as the patient was non-ambulatory and could not use a walker or gait trainer for all functional mobility due to decreased strength and poor endurance.  The patient could not use a standard wheelchair as the seating was too upright and too large and would not provide adequate postural support.  The patient required a dependent mobility device that provided adequate postural support for upright sitting.  The patient had trialed the cricket during the assessment.  The seating was appropriate.  The recommended model had growth for several years and its adjustable back reclining allowed for sitting with more upright spinal posture and head control.  The transit option was essential for increasing safety with transport in a motor vehicle.  This feature ensured that the frame of the wheelchair had been crushed tested and could not be safely secured in the motor vehicle without vehicle modification.  The backrest height extension was to provide the additional support needed as the patient grew.  A chest belt and pelvic harness were necessary for postural support and increase safety with trunk and pelvic positioning in the chair.  Fix locks were needed to mail the seatbelt and harness securely to the frame of the cricket.  The armrests were essential to provide an upper extremity weightbearing surface to assist with positioning in the chair and provide additional postural support.  The heel straps and calf straps were needed to promote optimal lower extremity positioning.  Since the start of the pandemic the patient's hamstrings have gotten tighter, causing him to pull his feet back underneath him.  The support would prevent him from doing so and would promote improved lower extremity alignment.  The upper extremity support tray was essential to provide an upper extremity weightbearing surface for the patient to push into for increased postural control.  The patient's mom walked everywhere with him to and from medical and therapy appointments.  It was noted protection from the elements was critical for his health.  The folding type of canopy was essential to protect him from the direct light of the sun which was irritating to him to protect him from extreme heat and cold.  The storage basket was to carry diapers, braces, feeding supplies, and a change of clothing for proper and daily care.  The request was made for a wheelchair and accessories as noted. 

Based on the medical documentation, the healthcare plan did not act reasonably, with sound judgement, in the best interest of the patient. The patient is non-ambulatory and could not use a walker or gait trainer for all functional mobility due to decreased strength and poor endurance; could not use a standard wheelchair as the seating was too upright and too large and would not provide adequate postural support. According to the current medical literature, in patients with decreased function and inability for independent mobility, the above requested durable medical equipment (DME) is recommended.

Based on the medical documentation, the claimant has a history of spastic diplegia, septo-optic dysplasia, hydrocephalus, and a ventriculoperitoneal (VP) shunt. According to the current medical literature, in patients with decreased function and inability for independent mobility, the above requested DME is recommended. He is non-ambulatory and could not use a walker or gait trainer for all functional mobility due to decreased strength and poor endurance; could not use a standard wheelchair as the seating was too upright and too large and would not provide adequate postural support. Additionally, he requires a dependent mobility device that provides adequate postural support for upright sitting. Therefore, the request is considered medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

the insurer's denial of coverage for wheelchair and accessories is overturned. medical necessity is substantiated.