Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, report of decreased hearing, coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, and intermittent back pain
Treatment: Installation of One Indoor Stairlift
The insurer denied: Installation of One Indoor Stairlift
The denial is upheld.

The patient is an elderly female. The records indicate that she has a history that includes report of dementia, report of decreased hearing, coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, and intermittent back pain. She has been living alone in the community in a home with two (2) floors with a flight of stairs in between (14 steps total) and approximately 6 or 7 steps to enter the home from the outside. Last year, the patient was hospitalized with weakness, hypotension, and leg edema. After three days in the hospital, she was transferred to a rehabilitation facility before returning home with a home attendant four hours per day. She received an increase in her home attendant hours to six hours per day, seven days per week. She had an alert bracelet but did not use it after one of her falls, leaving her on the ground until the next day when the home attendant returned. A physical therapy evaluation three months ago noted that the patient required contact guard assist for bed to chair transfers, contact guard assist for toilet/commode transfers, and moderate assist for tub/shower transfers. She needed moderate assist to negotiate six stairs. She was deemed to be homebound. As of discharge from the home therapy agency three months ago, she was reported to be independent with ambulation for 100 feet with a walker, with access to all her rooms, with no taxing effort noted. She was negotiating seven stairs with occasional contact guard assist. A community health assessment by a registered nurse two months ago noted that the patient's short-term memory was impaired but situational memory was okay. There was frequent bladder incontinence and occasional bowel incontinence. She was noted to require extensive to maximal assist for tasks such as transfers, toilet use, and dressing. She was reported to require assistance from two or more helpers for bathing. She was at maximum to total assist for instrumental activities of daily living. She was observed to ambulate on her own with a walker, albeit with unsteadiness. It was reported that she requires maximal level assist for negotiating stairs. She is reported to be alone at night. She has been staying on the first floor of her residence, which is reported to have become her living quarters. There is a half bathroom on the first floor. There is a full bathroom on the second floor. She is alternatively reported to have a walk-in shower with shower chair or a bathtub. Coverage of a stair lift for more independent access of the second floor, including for use of the full bathroom with bathing/showering facilities, has been requested. The health plan denied coverage of the service under review, indicating that the service is not medically necessary. This denial is being appealed.

The requested Installation of One Indoor Stairlift is not medically necessary.

The requested stair lift is not medically necessary, as there are no indications that the patient's activities of daily living needs cannot be met with her current setup without the stair lift. 

The patient has a half bathroom for use in her current living quarter level. She can access the second floor with home health aide assistance if she electively decides to access this floor, but there is no medical need for access of this floor. Her overall independence would not be increased with a stair lift, as she would remain dependent on assistance from others for her showers or baths regardless. Importantly, if she were to use the stair lift at a time when she is alone, e.g., to take a shower/bath in her second-floor bathroom, her risk for fall and serious injury would be expected to be significantly increased.