Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cerebral Palsy
Treatment: Medical necessities bag;
Push handles;
Custom mini knee flex;
Custom elbow stops;
Custom back cushion
The insurer denied the Medical necessities bag;
Push handles;
Custom mini knee flex;
Custom elbow stops;
Custom back cushion
The denial is overturned, in part.

The patient is a male with history of ataxic Cerebral Palsy associated with spastic quadriplegia since birth due to insult to his basal ganglia. He has physical, intellectual and motor planning issues along with seizures. He is dependent for all activities due to limitations in mobility, strength/stability, postural control, balance and endurance, all affecting his functionality and independence. He therefore requires significant assistance, and is dependent with all ADLs (activities of daily living).

The request is for accessory items for a powered wheelchair, including medical necessity bag, push handles, mini-knee flex, elbow stops and custom back cushion. It is noted that these are needed because of his disability and associated functional limitations with required and necessary additions to his powered wheelchair.

The requested accessories were not approved coverage by the health plan for the following reasons: For the custom back cushion, the patient has no fixed problem with posture, and another positioning cushion can be used. For the medical necessities bag, it serves no medical purpose. For the push handles, they are already included with the wheelchair and it is duplicate. For the mini-flex knee and custom elbow stops, similar items are already approved under separate components and they are duplicates.

Yes, the requested health service is medically necessary, in part.

The following are the requested accessories:

1) Push Handles (K0108): This enables the wheelchair to be manually pushed if the battery fails.
2) Custom Mini Flex Knee Blocks (K0108): Helps to maintain posture, hip abduction due to spasticity and excessive hip thrust.
3) Custom Elbow Stops (K0108): Helps to maintain posture and control spasticity and extension of the elbow.
4) Custom Wheelchair back Cushion (E2617): helps with pressure to prevent pressure ulcers due to shear, maintain posture and prevent contractures with increasing spasticity.
5) Medical Necessities bag (K0108): This enables him to take with him some clinical necessities.

The requested accessories were not approved coverage by the health plan for the following reasons: For the custom back cushion, the patient has no fixed problem with posture and that another positioning cushion can be used. For the medical necessities bag, it serves no medical purpose. For the push handles, they are already included with the wheelchair and that it is duplicate. For the mini-flex knee and custom elbow stops, similar items are already approved under separate components and they are duplicates.

Based on the above reasons for the listed accessories, in conjunction with the above reasons given by the health plan for denial, the custom back cushion is medically necessary, as the patient is stated to have spastic quadriplegia, which creates a fixed postural problem that may be associated with shear force that can potential lead to pressure ulcer. A custom-made cushion, as compared to an off-the-shelf cushion, will properly fit into the specific contour and posture of the patient. For the medical necessities bag, this is medically necessary in view of level of dependence of the patient for ADLs (activities of daily living), and the need to take along with him some clinical necessities that will require being carried along, and therefore it is medically necessary for a bag attachable to the wheelchair.

For the other items, while they are medically appropriate, if they are duplicates as the health plan notes, then it is not medically necessary to approve coverage of a duplicate set. Otherwise, they would be considered medically necessary for the reasons noted above.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The patient has history of Cerebral Palsy with severe weakness and contractures for which he needs a requested accessories to a power-wheel chair to facilitate transfer/change of position with easy navigation of ramps, to help in improving pressure relief to prevent further skin irritation and skin breakdown leading to pressure ulcers, help prevent increasing contractures, help posture control further helping his respiration & digestion, and to help Activities of Daily Living by using tilt and recline which will effectively offload pressure to the areas prone to pressure ulcers (especially the sacrum and the hips). This is needed also because he is more likely to be in the PWC (power wheelchair) for many hours a day.