Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Power Wheelchair (PWC) with numerous accessories, codes K0861, E2363x2, E2300, E2377, E1028, E1228x10, E1007, E2231, E2627x2, E1225, E2313, E2323, K0108x4, E2311, K0040x2, E0956x4, K0108, E1030, E2629, E2624, E0955, E0957x2, E2340, E2322, E2321, E2373, E2228x2, E2342, E0950, E0960, E0953x2
The insurer denied coverage for PWC with numerous accessories, codes K0861, E2363x2, E2300, E2377, E1028, E1228x10, E1007, E2231, E2627x2, E1225, E2313, E2323, K0108x4, E2311, K0040x2, E0956x4, K0108, E1030, E2629, E2624, E0955, E0957x2, E2340, E2322, E2321, E2373, E2228x2, E2342, E0950, E0960, E0953x2
The denial is overturned.

This is a review for a female requesting a power wheelchair (PWC) with numerous accessories. The member has multiple sclerosis. She currently has a PWC that is a Permobil M300 Corpus 3G (wheelchair model) with power tilt, power recline, power seat elevator and power elevating leg rests. Her current chair has had repairs to switch box, joystick, retractable joystick hardware, head rest bracket, seat cushion, battery charger, arm pads, wheel rims, rear casters and batteries. It is noted that she is having difficulty with inclines and ramps with her current chair, so she is looking to have her chair replaced with a new one. She also has an aide to assist with her care 24 hours a day, seven days a week.

Her physician reports that the therapist indicates the power tilt and recline is broken on the current chair, so that the member cannot be tilted or reclined and has been bed ridden more, due to the state of her current PWC. The physician notes that the member is quadriplegic, upper extremities are weak, she cannot reposition herself, and cannot maintain an upright posture. Further noted, is the member has 3+ (positive) edema to lower extremities so she needs to be able to elevate her legs. Seating evaluation for a new wheelchair was done.

Request for a standing PWC, which is the one feature her old PWC does not have is medically necessary. The member's old PWC had all the accessories other than standing; the member then had to use a manual stander with physical therapy. Having the standing capability allows the member's body to maintain bone structure since she is limited in her ability to move, stand, and sit on her own. The plan did not indicate why a new PWC is denied, and the member's needs were such that she required a PWC, and the member's status has not improved such that a PWC would not be considered appropriate. She spends a significant amount of time in her chair daily. Currently she is forced to rent a power wheelchair as her current chair is inoperable. The goal of a wheelchair is to allow a person to participate in social activities and activities of daily living, giving them as much independence as possible.

According to literature, "Spearman correlation coefficient showed that the frequency of using tilt, recline, and leg rest is significantly correlated with discomfort intensity. Multiple regression analysis with backward stepwise indicated that these functions can explain in the discomfort intensity score. The best-first decision tree shows that the frequency of using the leg rest function was the top node, followed by recline and tilt functions. The overall accuracy of prediction with ten-fold cross validation for discomfort intensity was 79.4%." (Wu et al., 2017).
The member's PWC is more than five years old, and evaluations done on the chair indicate the chair is not functional and requires further repairs. The member is currently renting a PWC that is not adjusted for her, and due to her diagnosis and impairments the member needs a chair that can recline and tilt.      
                                         
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 standing PWC with numerous accessories, codes K0861, E2363x2, E2300, E2377, E1028, E1228x10, E1007, E2231, E2627x2, E1225, E2313, E2323, K0108x4, E2311, K0040x2, E0956x4, K0108, E1030, E2629, E2624, E0955, E0957x2, E2340, E2322, E2321, E2373, E2228x2, E2342, E0950, E0960, E0953x2 is reversed. Medical Necessity is substantiated.