Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is requesting reimbursement and authorization and coverage for a powered pressure-reducing air mattress. The enrollee has a past medical history of congestive heart failure (CHF), deep venous thrombosis (DVT), gastroesophageal reflux disease (GERD), chronic pain of both lower extremities, morbid obesity with body mass index (BMI) of over 70, ventral hernia, dyspepsia, pre-diabetes, chronic pain syndrome, recurrent major depressive disorder (MDD), injury of left knee, abnormal vaginal bleeding, pulmonary embolism, long term (current) use of opiate analgesic, amphetamine abuse, cocaine abuse, obstructive sleep apnea (OSA), and history of dyspnea. The enrollee fell on New Years Eve and was taken via ambulance to the emergency department. She has left knee popping and stays in bed the majority of the day. She has not completed imaging due to difficulty with ambulation. The enrollee weighs over 400 pounds. She has a wound prevention bariatric low air loss mattress that also relieves pain from sciatica. It helps with breathing complications from chronic obstructive pulmonary disease (COPD), congestive heart failure and sleep apnea; and helps lift her legs, which are edematous. The medical literature denotes the classification for a BMI greater than 40 is class three, severe obesity. The enrollee is at risk for other medical conditions, including diabetes, as she is noted to have pre-diabetes, and various skin injuries, including pressure ulcers. Powered pressure-reducing air mattresses are indicated for patients with stage two, three or four pressure ulcers, and are also used for the prevention of pressure ulcers in high-risk patients. The enrollees CHF and COPD, plus the physical stress of mobility associated with severe obesity, contribute to respiratory compromise and decreased exercise tolerance. She has chronic pain in the lower extremities. Obesity is associated with osteoarthritis, typically of the knees. The enrollees fall resulted in acute pain to left knee and difficulty ambulating. Obesity increases the risk of pressure ulcers due to decreased mobility. Preventing pressure ulcers for an obese patient can have added challenges due to the difficulty with turning and positioning the patient; either by the patient or caregivers. Implementing a prevention plan is a high priority for the management of pressure ulcers due to the potential for significant morbidity from pressure ulcers. The enrollee has significant risk factors for pressure injury, including severe obesity, decreased mobility, and symptoms associated with cardiopulmonary disease. Pressure relief surfaces often used in bed, such as foam/gel overlays, may not be as effective for a person with severe obesity. Pressure-reducing air mattresses are often utilized after pressure ulcers occur. However, for high-risk patients, the benefit of utilizing more advanced methods of prevention must be judged with consideration of the potential harm if pressure ulcers occur. The enrollee has not had pressure ulcers. With risk factors of severe obesity and limited mobility, it is reasonable to consider the use of a powered air mattress has been a positive factor in preventing pressure ulcers for this enrollee. Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in internal 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 similar medical condition.