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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power elevating leg rests/articulating foot platform with seat elevation and standing feature, recline for an already approved group 3 power wheelchair with tilt-in-space. Researchers note that power seat functions may provide pressure relief, pain relief, and soft tissue stretching for individuals who are in wheelchairs for substantial periods of time during the day. In this case, the records document that the patient has chronic incomplete tetraplegia, with severe functional deficits. He requires maximum total assistance for his basic ADLs, and assistance from others for bodily hygiene tasks, which may require flat positioning while in the power wheelchair so that he can be rolled from side to side. In this clinical setting, given that providing proper skin hygiene is not possible without power recline and power leg elevation to flatten the body for rolls, power recline, and power leg/foot platform elevation are medically indicated. Researchers note that there is little data available to support standards development related to independent wheelchair transports. While power seat elevation may assist a user to independently transfer to and from a power wheelchair, the available records note that this patient requires maximum assistance for transfers with only trace to fair minus upper limb strength. The records do not include documentation of any transfer trials, and do not indicate that the patient would be able to safely perform independent transfers using this feature. Given that the patients environment may be adjusted to optimize his independence, such as with respect to reach, the requested seat elevation is not medically indicated. There is a lack of evidence in current medical literature that regular passive standing, such as that achieved with a standing frame, provides clinically significant benefits with respect to muscle function, skin integrity, bone health, respiratory function, digestive function, urinary function or other organ system functions in the setting of severe neurological weakness. In a systematic review of 17 studies, researchers concluded that while supported standing could prevent small losses of ankle mobility, the clinical importance of these effects was uncertain and low-dose standing was unlikely to protect bone health. While a standing frame may allow the user to interact with nonwheelchair users at eye level, such interaction is not a medical necessity to accomplish mobility-related activities of daily living. Given the lack of evidence showing that the requested equipment results in clinically significant improvement to health and functional outcomes, the requested standing feature is not medically indicated. Therefore, power elevating leg rests/articulating foot platform and power recline for an already approved group 3 power wheelchair with tilt-in-space are medically necessary for the patient to perform one or more mobility related ADLs or instrumental ADLs in or out of the home, including access to the community.Final Result: The reviewer determined that a portion of the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.