Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Durable Medical Equipment {DME) {including Wearable Defibrillators)
Diagnosis: ALS
Treatment; Power Wheelchair/Accessories
The insurer denied the Power Wheelchair/Accessories. The health plan's determination is overturned in part.
The patient is a male with diagnosis of Amyotrophic Lateral Scoliosis {ALS) who is seeking approval for a power wheelchair and accessories.
The Request is for a grade 3 power wheelchair with upgrade to grade 4. A group 4 power wheelchair offers tilt, recline, power elevating leg rests and standing. This patient has had his current wheelchair for 4 years. Unfortunately, ALS is a progressive neurologic disease and the patient has become weaker.
Documentation notes that he spends his entire day in his wheelchair. The patient's postural abnormalities and destructive postural tendencies as well as his pain can only be treated with multiple positioning components to provide adequate stability and support. Therefore, it is medically necessary to have a wheelchair with ability to tilt/recline for adequate pressure relief and prevention of pressure sores. Elevating leg rests are also necessary to allow for edema management.
A standing feature and its necessary accessories, though, is not medically necessary. Pressure relief can be successfully obtained with a tilt/recline feature. In addition, a standing frame combined with physical therapy can provide the same benefits listed above and is the acceptable standard of care. Also, while one might point out that it was noted that Easy Stand sit to stand version was "very painful for the patient to be positioned in the easy stand due to the nature of how the stander works" there are different versions that still can be tried. EZ lock is medically necessary to safely transport the patient in his vehicle. He requires EZ lock to allow his wheelchair to be secured while driving. Anti-tippers are required to prevent his wheelchair from tipping backwards.
Power adjustable seat height is medically necessary to allow the patient to perform activities of basic living, such as reaching for food at higher levels and being able to eat, when his spouse is not present. It will allow him the accessibility to reach into bathroom cabinets for medication, turn off/on light switches. In addition, this will allow him the ability to raise up to items instead of requiring him to reach. Group 24 Batteries sealed gel installed is not medically necessary as a sealed lead acid battery will provide the necessary power for his chair.
LED light kit is not medically necessary and considered for comfort and convenience. Retractable joystick mount is medically necessary to allow for safe transfers. Harness and Rnct expandable required for expandable controller is medically necessary. Attendant control R- net is not medically necessary as documentation supports that the patient is capable of controlling his motorized wheelchair independently. Multiple seat function control kit for R net is medically necessary. Corpus Ergo back, stretch air cushion is medically necessary as his abnormal posture is progressive and cannot be treated with prefabricated backs and cushions. Corpus arm with Permobil gel bed is not medically necessary as the patient does have the upper extremity strength to properly reposition. Armrest side supports are medically necessary. Elbow supports are also medically necessary. Corpus V knee abductors with adjustable removable knee hardware are medically necessary as documentation lower extremity strength is impaired and will continue to progress. Wide corpus footplate is medically necessary due to impaired hip range of motion. Calf support kit is medically necessary secondary to impaired lower extremity strength. Body point padded hip belt 2 point is medically necessary as documentation noted posterior pelvic tilt and forward left ASIS.
Whit Myer Headrest with plush pad, detachable hardware and headrest adapter are medically necessary as documentation noted hyperextension of neck/head without occipital and forehead support. Dynamic forehead strap is medically necessary as documentation noted hyperextension of neck/head without occipital and forehead support. Lateral hip support pads with mesh cover and adjustable removable hardware for hip supports are medically necessary secondary to impaired lower extremity strength.Bag hooks are not medically necessary and considered for comfort and convenience. Body point chest belt is medically necessary for safety. OHO Quadtro cushion is medically necessary to allow for adequate pressure relief for accommodation of pelvic obliquity. PermobiI tray UESS with adjustable hardware is not medically necessary and considered for comfort and convenience. While the PowerTech Vent Power Center does allow for a tighter turning radius and longer battery life this is not medically necessary as there are other ways to power your vent.