Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legg Calve Perthes Disease

Treatment: K0007 Wheelchair

The insurer denied coverage for K0007 Wheelchair

The denial is overturned
 

This patient is a teenager who had right femoral and pelvic osteotomies for right hip deformities due to Legg Calve-Perthes disease. There was a request for a manual wheelchair since the patient was non-weight bearing. 

A letter submitted notes the patient has significant right hip pain and is recommended to use a wheelchair for mobilization for long distance activities in school and in the community. 

New York State Medical Program Guidelines note wheeled mobility equipment is covered if the patient's medical conditions and mobility limitations are such that without the use of the wheeled mobility equipment (WME), the patient's ability to perform mobility related activities of daily living (MRADL) in the home and/or community is significantly impaired and the patient is not ambulatory or functionally ambulatory, as is the case with this patient.

Per Do, D. H., McGuire, M. F., Jo, C. H., & Kim, H. K. W. (2021), "In general, weightbearing and activity restrictions were recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and moderate to severe femoral head involvement on magnetic resonance imaging (MRI) or as a postoperative regimen. Prescribed weightbearing and activity restrictions described in the patient chart were categorized into four regimens, with each level being distinct from the next to ensure reproducibility. During the period of this study, patients who were asymptomatic and had favorable progression of femoral head deformity were prescribed the no-restriction regimen, which consisted of patients who were allowed to bear weight as tolerated and were allowed to participate in all activities. Patients who had low femoral head involvement, were mildly symptomatic, or were recovering from previous surgery were assigned to the mild-restriction regimen, which included patients who were allowed to return to normal walking, but not sports, physical education class at school, running, or jumping. Patients who had adequate hip range of motion (ROM) but were at risk of femoral head collapse were assigned to the moderate-restriction regimen, which included patients who were non weight bearing, toe-touch weightbearing, or partial weight bearing to the affected hip with the use of a wheelchair, a walker, and/or crutches for mobility. Patients who had a high degree of hip stiffness were designated to the severe-restriction regimen, where patients were treated with a Petrie abduction cast, a hip spica cast, or an A-frame abduction orthosis plus were non weightbearing on the affected side."

A recent letter notes the appeal for a bariatric manual wheelchair. The patient has experienced worsening right hip deformity and pain over time which has significantly limited his mobility and participation in daily activities. The wheelchair will allow for extended periods of mobilization in order to participate in school activities and activities in the community. The patient should have been provided at manual wheelchair (rental or purchase) for three (3) months or until he can weight bear and maneuver in school. Attending school is a necessity for a child.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for durable medical equipment (DME) K0007 x 1, wheelchair is substantiated.