Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unsteady on feet
Treatment: Environmental stair lift
The insurer denied the environmental stair lift.
The health plan's determination is overturned.

The patient is a female with past medical history of stroke with hemiparesis, monoplegia of upper and lower limbs, hypertension, deep vein thrombosis (DVT), and pulmonary embolism. The patient also has a history of chronic anticoagulation, diabetes mellitus type 2, neuropathy, edema, urinary incontinence, chronic obstructive pulmonary disease (COPD), depression, gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), osteoarthritis, and asthma. The patient underwent a video teleconference universal assessment for personal care assistant (PCA) services assessing the patient at total assistance with tasks of ordinary housework, stairs, shopping and locomotion. She was assessed as needing maximum assistance with tasks of meal preparation, transportation, bathing, dressing upper and lower body, toilet transfers and toilet use. Notes from this assessment stated the patient had no informal help and the patient lived alone in a 1 bedroom home with 4 steps into the house. The patient was assigned Consumer Directed Personal Assistance Program (CDPAP) services 40 hours/week. The patient's medical provider submitted a prescription for a stair lift with lifetime need, if not provided the patient will not go to a nursing home. The plan denial stated the patient's care manager could help her explore organizations that may help the patient get a stair lift and the patient could use a walker and wheelchair to move about her environment and the plan would provide the patient with door-to-door transportation for medical appointments. The plan noted a stair lift would not help the patient to become more independent and recommended discussing physical therapy with her medical provider to help the patient move safer in her home and the patient could be referred to social worker to discuss community resources and other options. 

The patient provided a letter stating her stroke affected her left arm and right leg and that she had spent many months in multiple rehabilitation centers but mobility was still a great challenge. 

The patient's medical provider completed documentation for the Department of Health stating the patient needed a power scooter for mobility, the patient was receiving physical therapy and home health aide services, and the patient required total assistance with walking inside and outside of the home. 

The patient's healthcare advocate provided a letter stating the patient required physical assistance with all activities of daily living (ADLs) and the patient is unable to ambulate on her own. The patient's stairway of her home was too narrow and steep to install a ramp.

The patient did not have the ability to safely leave her home without physical assistance. In addition, the advocate's letter stated a stair lift was medically necessary because it would increase the patient's capacity for normal activity and correct a condition that causes acute suffering and endangers life as the patient cannot ascend or descend the stairway on her own. The letter also stated the insurer did not refer to any medical documentation and did not communicate with the patient's primary care physician (or provider) (PCP) to confirm the medical necessity for a stair lift. Lastly, the advocate letter stated the plan did not offer any other solutions to allow the patient's safe access to and from her home.

The environmental stair lift is medically necessary to prevent, diagnose, correct, or cure conditions in the patient that is causing acute suffering, endangering life, resulting in illness or infirmary, and interfering with the patient's capacity for normal activity or threatening some significant handicap. There is documentation that the patient is unable to ambulate on her own.