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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ultralightweight wheelchair (HCPCS K0005), skin protection wheelchair seat cushion width 22 inches, any depth (HCPCS E2622), manual wheelchair accessory, pneumatic propulsion tire, any size x 2 (HCPCS Codes E2211), and pneumatic propulsion tire insert x 2 (HCPCS E2213). The records provided for review document that this patient is non-ambulatory due to sacral level spina bifida with chronic paraplegia, as well as due to her talipes equinovarus. She requires a wheelchair to perform all of her mobility-related activities of daily living and instrumental activities of daily living, as well as for community access. The patients upper limbs are reported to be functionally intact. The patients current wheelchair is now more than six years old, in disrepair, and no longer meets her seating and mobility needs. The patients current wheelchair cannot be reasonably repaired without risk of impending catastrophic failure, particularly given that the base wheelchair frame is compromised. Thus, the patient requires a new, replacement manual wheelchair. For a patient in this scenario, a manual wheelchair that is optimally fitted for propulsion is appropriate for independence, household mobility, community mobility, and maintenance of health (Michael, et al.). Considering this patients conditions, this level of fitting can usually only be achieved on a K0005 ultralight manual wheelchair and not a K0004 or other lower level manual wheelchair (Medola, et al.). Modifying the axle position is critical for optimizing propulsion biomechanics for efficiency and mitigating risk of injury from overuse is a feature that is only available on K0005 class wheelchairs (Bertolaccini, et al.). A rigid wheelchair frame from the ultralightweight class would increase the patients independence in the community, especially on uneven surfaces and reduce injury from overuse. In the current case, the patient has undergone a specialty seating and mobility evaluation that has confirmed that the required fitting adjustments can only be provided on a K0005 level custom ultralight manual wheelchair including the adjusted axle placement. The patient also requires pneumatic tires with inserts to provide a reasonably cushioned ride in the home and community, while still allowing for propulsion in the event of air loss in the tires, brake extensions, an appropriate foot plate for resting her feet, a skin protection positioning seat cushion, side guards to protect the wheel spokes from her clothes, a seat pouch to store her medical supplies, anti-tippers for safety, and push handles for caregiver assisted propulsion as needed. Without the recommended replacement ultralightweight manual wheelchair and accessories, the patients independence and health would be significantly and inappropriately compromised. Moreover, the requested ultralightweight wheelchair and accessories are consistent with the recommendations in the medical literature. For these reasons, the requested ultralightweight wheelchair (HCPCS K0005), skin protection wheelchair seat cushion width 22 inches, any depth (HCPCS E2622), manual wheelchair accessory, pneumatic propulsion tire, any size x 2 (HCPCS E2211), and pneumatic propulsion tire insert x 2 (HCPCS E2213) are medically necessary for the patient to perform one or more mobility related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 a similar medical condition.