No. 03-15-00226-CV

_________________________________ 

IN THE 

THIRD COURT OF APPEALS 

AUSTIN, TEXAS

_________________________________ 

TEXAS HEALTH AND HUMAN SERVICES COMMISSION, 

Appellant,

v.

LINDA PUGLISI, 

Appellee. 

_________________________________ 

On Appeal From 

The 53rd Judicial District Court of Travis County, Texas 

Trial Court Case No. D-1-GN-14-000381 

The Honorable Judge Gisela D. Trianna 

_________________________________ 

BRIEF OF APPELLEE 

_________________________________ 

MAUREEN O’CONNELL

Texas Bar No. 00795949 

SOUTHERN DISABILITY LAW CENTER 

1307 Payne Avenue 

Austin, Texas 78757 

T: 512.458.5800 

F: 512.458.5850 

moconnell458@gmail.com 

Attorney for Appellee 

ORAL ARGUMENT REQUESTED

ACCEPTED

03-15-00226-CV

6056931

THIRD COURT OF APPEALS

AUSTIN, TEXAS

7/14/2015 12:54:37 PM

JEFFREY D. KYLE

CLERK

 FILED IN 3rd COURT OF APPEALS AUSTIN, TEXAS 7/14/2015 12:54:37 PM JEFFREY D. KYLE Clerk
i

TABLE OF CONTENTS

TABLE OF CONTENTS............................................................................................i

TABLE OF AUTHORITIES ................................................................................... iii

ISSUES PRESENTED...............................................................................................x

LEGAL FRAMEWORK OF THE MEDICAID PROGRAM ..................................2

STATEMENT OF FACTS ........................................................................................4

SUMMARY OF THE ARGUMENT ........................................................................9

ARGUMENT...........................................................................................................11

A. The Trial Court Correctly Denied HHSC’s Motion to Dismiss .................11

B. The Trial Court Correctly Reversed and Remanded the Case 

to HHSC for Further Proceedings Consistent with Its Decision ................16

C. Deference is Not Owed to HHSC’s Post-Hoc Interpretation of 

Agency Rules..............................................................................................18

D. The Trial Court Correctly Determined that HHSC’s Hearing 

Decision Fails to Comply with Medicaid Law ...........................................20

E. The Trial Court Correctly Determined that HHSC’s Hearing 

Decision is Arbitrary, Capricious, Unreasonable and 

Unsupported by Substantial Evidence ........................................................22

1. The trial court properly addressed the two reasons 

Molina denied Linda Puglisi’s prior authorization request.................22

2. HHSC failed to address Linda Puglisi’s medical need for 

a custom power wheelchair with integrated standing 

feature..................................................................................................24

3. HHSC failed to employ the correct test for determining 

Medicaid coverage of DME ................................................................34
ii

F. HHSC Violated Linda Puglisi’s Procedural Due Process 

Rights ..........................................................................................................45

1. Medicaid beneficiaries have a protected property interest 

in their Medicaid benefits....................................................................45

2. Molina’s denial notice does not comport with due 

process and HHSC failed to address this issue ...................................47

3. HHSC’s administrative review does not comport with 

State law and further compounded the due process 

violations in this case ..........................................................................49

PRAYER..................................................................................................................49

CERTIFICATE OF COMPLIANCE.......................................................................50

CERTIFICATE OF SERVICE ................................................................................51
iii

TABLE OF AUTHORITIES

CASES

Ability Center of Toledo v. Lumpkin, 

808 F.Supp.2d.1003 (N.D. Ohio 2011) ..............................................................46

Allegent Health v. Amer. Farm Ins., Inc., 

656 N.W.2d 906 (Neb. 2003) .............................................................................12

Alvarez v. Betlach, 

572 F. App’x 519 (9th Cir.)................................................................................36

Baker v. Commonwealth of Pa. Dept. of Pub. Welfare, 

502 A.2d 318 (Pa. Commw. 1985)...............................................................36, 37

Bell v. Agency for Health Care Admin., 

768 So.2d 1203 (FL. App. 2000)..................................................................36, 37

Blue v. Bonta, 

99 Cal.App. 4th 980, 121 Cal.Rptr.2d 483 (Cal App. 2002)..............................36

Bowers v. Thompson; 

No. 89-2-00553-8 (Wash. Super. Ct. Thurston County Oct. 15, 1990) .......36, 37

Brisson v. Dep’t of Social Welf.,

702 A.2d 405 (VT. 1997)..............................................................................36, 37

Bristol v. R.I. Dept. of Hum. Serv., 

1997 WL 839884 (R.I. Super. Jan. 30, 1997).....................................................36

Combs v. Entertainment Publications, Inc.,

292 S.W. 3d 712 (Tex. App.—Austin 2009, no pet.).........................................42

Davis v. Shah, 

2012 WL 1574944 (W.D.N.Y. May 3, 2012).....................................................36

Davis v. Shrader, 

687 N.E.2d 370 (Ind. App. 1997).................................................................36, 37
iv

DeSario v. Thomas,

139 F.3d 80 (2d Cir. 1998) .................................................................................37

Detgen v. Janek,

945 F. Supp. 2d 746 (N.D. Tex. 2013)...............................................................23

Detgen v. Janek,

752 F. 3d 627 (5th Circuit 2014) ............................................................35, 36, 37

El Paso Hosp. Dist. v. Texas Health and Human Servs. Comm’n,

247 S.W. 3d 709 (Tex. 2008) .............................................................................43

Evanston Hosp. v. Hauck, 

1992 WL 205900 (N.D. Ill. 1992)......................................................................12

Fishman v. Daines, 

743 F.Supp.2d. 127 (E.D. N.Y 2010).................................................................46

Frank v. Thomas,

No. 3:98CV00306(GLG), U.S. Dist. Ct., D. Conn. 1998...................................15

Fred C. v. Texas Health & Human Services Comm’n, 

988 F.Supp. 1032 (W.D.Tx. 1997).....................................................................36

Goldberg v. Kelly,

397 U.S. 254 (1970)............................................................................................45

Gray Panthers v. Schweiker,

652 F. 2d 146 (D.C. Cir. 1980)...........................................................................47

Hamby v. Neel,

368 F.3d. 549 (6th Cir. 2004) .......................................................................45, 46

Hiltibran v. Levy,

793 F.Supp.2d 1108 (W.D. Mo. 2011)...............................................................36

Hunter v. Chiles,

944 F.Supp. 914 (S.D. Fl. 1996)...................................................................36, 37
v

Jasset v. R.I. Dept. of Hum. Serv.,

2006 WL 2169891 (R.I. Super. July 31, 2006) ..................................................36

Johnson v. Guhl, 

91 F.Supp. 2d 754 (D. N.J. 2000).......................................................................46

Johnson v. Minn. Dept. of Human Serv., 

565 N.W.2d 453 (Minn. App. 1997) ............................................................36, 37

Jonathan C. v. Hawkins, 

2006 WL 3498494 (E.D. Tex. Dec. 5, 2006) .....................................................45

Koenning v. Janek,

539 Fed. Appx. 353 (5th Cir. 2013)....................................................................39

Koenning v. Suehs,

897 F. Supp.2d 528 (S.D. 2012).........................................................................39

Ladd v. Thomas,

962 F. Supp 284 (D. Conn. 1997).................................................................45, 46

Lankford v. Sherman, 

451 F.3d 496 (8th Cir. 2006) ..................................................................34, 36, 37

Ledet v. Fischer,

638 F. Supp. 1288 (M.D. La. 1986)..............................................................36, 37

Liberty Mut. Ins. Co. v. Texas Dep't of Ins., 

187 S.W. 3d 808 (Tex. App. Austin 2006, pet denied)......................................46

Mayhew v. Town of Sunnyvale,

964 S.W.2d 922 (Tex.1998)................................................................................11

Meyers v. Reagen,

776 F.2d 241 (8th Cir. 1985) ..............................................................................36

Myers v. State of Mississippi,

3:95 CV 185 LN (Slip Op. S.D. Miss. 1995) ...............................................36, 37
vi

Neuwrith v. Louisiana State Bd. of Dentistry,

845 F. 2d 553 (5th Cir. 1988) .............................................................................46

Ohlson v. Weil,

953 P.2d 939 (Colo. App. 1997)...................................................................36, 37

Patterson v. Planned Parenthood of Houston & Se. Texas, Inc., 

971 S.W.2d 439 (Tex. 1998) ..............................................................................11

Perry v. Del Rio,

66 S.W.3d 239 (Tex. 2001).................................................................................16

Public Utility Commission v. South Plains Electric Cooperative, Inc.,

635 S.W.2d 954 (Tex.App.—Austin 1982, writ ref'd n.r.e.)..............................44

Rastetter v. Weinberger, 

379 F.Supp. 170 (D.AZ. 1974)...........................................................................12

Rodriguez v. Serv. Lloyds Ins. Co.,

997 S.W.2d 248 (Tex. 1999) ........................................................................21, 43

Roe v. Norton, 

522 F.2d 928 (2d Cir. 1975) ...............................................................................12

Skubel v. Fuoroli, 

113 F.3d 330 (2d Cir. 1997) ...............................................................................12

Slekis v. Thomas, 

525 U.S. 1098 (1999)..........................................................................................38

Stanford v. Butler,

181 S.W.2d 269 (Tex.1944)................................................................................19

Sw. Pharmacy Solutions, Inc. v. Texas Health & Human Servs. Comm’n,

408 S.W.3d 549 (Tex. App. 2013)......................................................................18

Tarrant Appraisal Dist. v. Moore,

845 S.W.2d 820 (Tex. 1993) ..............................................................................19
vii

Texas Alcoholic Beverage Comm’n v. Amusement & Music Operators of 

Tex., Inc.,

997 S.W.2d 651 (Tex. App.—Austin 1999, pet. dism’d w.o.j.).........................41

Texas State Bd. of Pharmacy v. Witcher, 

447 S.W.3d 520 (Tex. App. 2014)......................................................................43

Thompson v. Roob,

2006 WL 2990426 (S.D. Ind. Oct. 19, 2006)...............................................45, 48

T.L. v. Colorado Dept. of Health Care Policy & Fin.,

42 P.2d 63 (Colo. App. 2002).............................................................................36

Waco Indep. Sch. Dist. v. Gibson, 

22 S.W.3d 849 (Tex. 2000).................................................................................11

Weaver v. Reagan,

886 F. 2d 194 (8th Cir. 1989) .............................................................................25

Wilder v. Virginia Hospital Association,

496 U.S. 498 (1990)..............................................................................................2

Will T. v. Taylor,

465 F.Supp.2d 1267 (N.D. Ga. 2000).................................................................36

Woody v. Dallas,

809 F. Supp. 466 (N.D. Tex. 1992) ....................................................................46

REGULATIONS

1 TEX. ADMIN. CODE § 354.1031.......................................................................20, 39

1 TEX. ADMIN. CODE § 354.1031(b)(12)..............................................................3, 20

1 TEX. ADMIN. CODE § 354.1035.................................................................20, 21, 39

1 TEX. ADMIN. CODE § 354.1039.................................................................20, 21, 29

1 TEX. ADMIN. CODE § 354.1039(a) ..................................................................18, 19
viii

1 TEX. ADMIN. CODE § 354.1039(a)(4)(A)........................................................18, 19

1 TEX. ADMIN. CODE § 354.1039(a)(4)(D) ..............................................4, 20, 24, 38

1 TEX. ADMIN. CODE § 354.1040.............................................. 13, 20, 21, 39, 40, 42

1 TEX. ADMIN. CODE § 354.1040(d)(3)....................................................................13

1 TEX. ADMIN. CODE § 354.1040(g) ........................................................................13

1 TEX. ADMIN. CODE § 354.1041.............................................................................12

1 TEX. ADMIN. CODE § 354.1041(2)(B)...................................................................13

1 TEX. ADMIN. CODE § 354.2321(b) ........................................................................14

1 TEX. ADMIN. CODE § 354.2321(f).........................................................................14

1 TEX. ADMIN. CODE § 355.8021(b)(2-3)................................................................13

1 TEX. ADMIN. CODE § 357.3(b)(1)(E) ..............................................................46, 47

1 TEX. ADMIN. CODE § 357.9...................................................................................27

1 TEX. ADMIN. CODE § 357.703.................................................................................8

1 TEX. ADMIN. CODE § 357.703(b)(3)......................................................................42

42 C.F.R. § 431.10(e)(1)............................................................................................2

42 C.F.R. § 200 ........................................................................................................47

42 C.F.R. § 431.210(b) ......................................................................................31, 47

42 C.F.R. § 431.210(c).................................................................................18, 31, 47

42 C.F.R. § 435.930 ...................................................................................................4

42 C.F.R. § 438.210(a)(4)(i)....................................................................................28
ix

42 C.F.R. § 438.404 .................................................................................................47

42 C.F.R. § 440.70(b)(3)............................................................................................3

42 C.F.R. § 440.230(b) ..................................................................................3, 38, 44

42 C.F.R. § 440.230(c)...................................................................................3, 38, 44

42 C.F.R. § 440.240(a).............................................................................................34

STATUTES

42 U.S.C. § 1396........................................................................................................2

42 U.S.C. § 1396a(a)(3)...........................................................................................47

42 U.S.C. § 1396a(a)(5).............................................................................................2

42 U.S.C. § 1396a(a)(8).............................................................................................4

42 U.S.C. § 1396a(a)(10(B).....................................................................................34

42 U.S.C. § 1396a(a)(17)...............................................................................3, 38, 44

42 U.S.C. § 1396d(a)(7).............................................................................................3

42 U.S.C. § 1396w2...................................................................................................2

42 U.S.C. § 1396-1.....................................................................................................2

TEX. GOV’T CODE § 531.019(c).............................................................................1, 8

TEX. GOV’T CODE § 531.021(a).................................................................................2

TEX. GOV’T CODE § 2001.003(6).............................................................................41

TEX. GOV’T CODE § 2001.023..................................................................................43
x

TEX. GOV’T CODE § 2001.030..................................................................................43

TEX. GOV’T CODE § 2001.038............................................................................39, 40

TEX. GOV’T CODE § 2001.171....................................................................................1

TEX. HUM. RES. CODE § 32.0425 .................................................................19, 40, 42

OTHER AUTHORITIES

In the Matter of Mary A., New York Dept. of Social Services................................14

RESNA Position on the Application of Wheelchair Standing Devices, 

Assistive Technology, 21:161-168, 2009 ...................................................................6
xi

ISSUES PRESENTED

1. Did the trial court correctly deny HHSC’s motion to dismiss?

2. Did the trial court correctly reverse and remand the case to HHSC for further

proceedings consistent with the court's decision?

3. Did the trial court correctly determine that HHSC’s post hoc interpretation of 

agency rules is not entitled to deference?

4. Did the trial court correctly determine that HHSC’s hearing decision fails to 

comply with Medicaid law?

5. Did the trial court correctly determine that HHSC’s hearing decision is

arbitrary, capricious, unreasonable and unsupported by substantial evidence?

6. Did HHSC violate Linda Puglisi’s procedural due process rights as a Medicaid 

beneficiary? 
No. 03-15-00226-CV

_________________________________

IN THE

THIRD COURT OF APPEALS

AUSTIN, TEXAS

_________________________________

TEXAS HEALTH AND HUMAN SERVICES COMMISSION,

Appellant,

v.

LINDA PUGLISI,

Appellee.

_________________________________

On Appeal From

The 53rd Judicial District Court of Travis County, Texas

Trial Court Case No. D-1-GN-14-000381

The Honorable Judge Gisela D. Trianna

_________________________________

BRIEF OF APPELLEE

_________________________________

To the Honorable Third Court of Appeals:

This appeal arises out of a Medicaid hearing decision issued by the Texas 

Health and Human Services Commission (HHSC) denying Linda Puglisi’s request 

for Medicaid prior authorization of a custom power wheelchair with integrated 

standing feature. Linda filed a Petition for Judicial Review in the Travis County 

District Court to challenge this denial. TEX. GOV’T CODE §§ 531.019(c) and

2001.171 et seq. The trial court reversed the agency’s decision, finding it arbitrary, 
2

capricious, unreasonable, and unsupported by substantial evidence. The trial 

court's decision should be affirmed.

LEGAL FRAMEWORK OF THE MEDICAID PROGRAM

In 1965, Congress enacted Title XIX of the Social Security Act to establish 

Medicaid, a federal-state program designed to provide medically necessary health 

care to low income families and individuals with disabilities. 42 U.S.C. §§ 1396-

1396w2. The purpose of this program is to enable states “to furnish...rehabilitation 

and other services to help such families and individuals attain or retain the 

capability for independence or self-care.” 42 U.S.C. § 1396-1. State participation 

in Medicaid is optional, however, “once a state chooses to join, it must follow the 

requirements set forth in the Medicaid Act and its implementing regulations.” 

Wilder v. Virginia Hospital Association, 496 U.S. 498, 502 (1990).

The Centers for Medicare and Medicaid Services (CMS) provide federal 

oversight of state Medicaid programs, however, each state must designate a single 

state agency to administer its Medicaid program. 42 U.S.C. § 1396a(a)(5). HHSC 

is the designated Medicaid agency in Texas. TEX. GOV’T CODE § 531.021(a). As 

the single state agency, HHSC must comply with all federal Medicaid 

requirements when promulgating rules and establishing policy and cannot delegate

its authority on program matters to its contracted entities. 42 C.F.R. § 431.10(e)(1). 

HHSC’s contracted entities, which include managed care organizations and the 
3

Texas Medicaid and Healthcare Partnership (TMHP), must comply with all 

Medicaid legal requirements when deciding whether requested medical services 

will be approved for eligible beneficiaries.

At issue in this case is medical equipment, a required component of the 

Medicaid home health category of service. 42 U.S.C. § 1396d(a)(7); 42 C.F.R. § 

440.70(b)(3). Federal law does not presently define the term durable medical 

equipment (DME), however, the Health Care Financing Administration (now 

CMS) issued official guidance in 1998 concerning this mandatory Medicaid 

benefit. HHSC App. 6. Known as the DeSario Letter, this guidance clarified that 

state Medicaid programs must comply with the Medicaid Act’s reasonable 

standards requirement, 42 U.S.C. § 1396a(a)(17), and amount duration, and scope 

rule, 42 C.F.R. § 440.230(b-c), in administering the DME benefit. In 2013, CMS 

reaffirmed the continuing application of this federal policy when it wrote to 

HHSC’s Medicaid Director to explain that Texas Medicaid must provide DME 

when the requested item: (1) is a covered benefit; and (2) is medically necessary 

for the individual requesting it. Puglisi App. 1.

An item of medical equipment is covered by Medicaid if it meet HHSC’s 

definition of DME. Puglisi App. 1. By rule, 1 TEX. ADMIN. CODE § 

354.1031(b)(12), DME is defined as:
4

[m]achinery or equipment which meets one or both of the following 

criteria: (A) the projected term of use is more than one year; or (B) 

reimbursement is made at a cost of more than $ 1,000.

Texas Medicaid policy, TMPPM DME Handbook 2.2.2, further defines DME as:

Medical equipment or appliances that are manufactured to withstand 

repeated use, ordered by a physician for use in the home, and required 

to correct or ameliorate a client’s disability, condition or illness.

HHSC App. 4, 5.

An item of DME is medically necessary when “required to correct or 

ameliorate the individual’s disability, medical condition, or illness” or in 

exceptional circumstances, found to “serve a specific medical purpose.” TMPPM 

DME Handbook 2.2.2; 1 TEX. ADMIN. CODE § 354.1039(a)(4)(D). HHSC App. 4, 

5. Once these criteria - coverage and medical necessity - are met by an eligible 

beneficiary, HHSC or its contracted entity must prior authorize the requested item 

of DME with reasonable promptness. 42 U.S.C. § 1396a(a)(8); 42 C.F.R. §

435.930. 

STATEMENT OF FACTS

The facts underlying Linda Puglisi’s request for Medicaid prior 

authorization of a custom power wheelchair with integrated standing feature were 

largely uncontested at HHSC’s hearing. In 2011, Linda sustained a C1-4 spinal 

cord injury during surgery to remove a tumor from her neck. Puglisi App. 2, p.50.

This injury left her paralyzed, dependent upon a ventilator to breathe and a feeding 
5

tube for sustenance. Following months of hospitalization and inpatient 

rehabilitation, the ventilator and feeding tube were discontinued. Linda remained

paralyzed however, and is no longer able to walk. She requires a custom power 

wheelchair for all mobility. Puglisi App. 2, p. 50; App. 3, pp. 63-64; AR 310.

In February 2013, Linda was admitted to TIRR Memorial Hermann Hospital 

for physical rehabilitation. While there, she underwent a comprehensive 

wheelchair assessment, which provides extensive information concerning her 

disability and the numerous medical conditions she faces as a result. Puglisi App.

3, pp. 63-71: HHSC App. 2, Finding of Fact 3; App. 3, Finding of Fact 4. This 

evaluation explains that Linda has “impaired integumentary sensation, respiratory 

function, neurogenic bowel, and neurological pain.” She also faces an “increased 

risk for bone density loss and compromised soft tissue integrity secondary [due] to 

not being able to bear weight through [her bilateral lower extremities].” Puglisi 

App. 3, p. 64. 

The evaluation team recommended a custom power wheelchair with 

integrated standing feature to address Linda’s many medical conditions and to 

allow her to “independently perform pressure relief and weight bearing through her 

[lower extremities] preventing skin breakdown and bone density loss, as well as 

enhancing biomechanical alignment throughout the entire body on a daily basis, 
6

which helps to prevent further impact of spasticity on joints in upright postures.”1

Puglisi App. 3, p. 68-69. Linda’s attending physical medicine and rehabilitation 

specialist attested to her medical need for the recommended wheelchair with 

standing feature.2

As required, a Medicaid-enrolled DME supplier requested prior 

authorization of the recommended wheelchair from Molina Healthcare of Texas 

(Molina), a managed care organization under contract with HHSC. HHSC App. 2,

Findings of Fact 1, 4; App.3, Findings of Fact 1,5. Molina referred the request to a 

third-party entity “for review of medical necessity...” HHSC App. 2, Finding of 

Fact 5. This reviewer informed the DME supplier that it would have to substitute a 

different wheelchair base and remove the seat elevator and standing feature before 

Molina would approve a power wheelchair for Linda. AR 132-133. In response, 

the DME supplier submitted extensive documentation, including several 

professional publications explaining the medical benefits of standing for people 

with spinal cord injuries and their use of wheelchairs with integrated standing 

 

1 Custom wheelchairs with integrated standing systems are well-recognized in the rehabilitation 

profession as a means of addressing the “painful, problematic, and costly secondary 

complications” that result from prolonged sitting. These wheelchairs “allow for more frequent, 

random, and independent performance of standing” than separate standing devices. See RESNA 

Position on the Application of Wheelchair Standing Devices, Assistive Technology, 21:161-168, 

2009. Puglisi App. 4.

2 The recommended wheelchair has an integrated multi-positional standing system. This 

wheelchair requires a Group 4 base to accommodate the standing feature and several additional 

power seat functions, including tilt and recline, center mount articulating elevating leg rests, 

stand and drive leg rest assembly, and seat elevation, all of which are required to operate the 

standing function. Puglisi App. 5, ¶5.
7

features. AR 47-117. This documentation also included additional medical 

justification by Linda’s attending physician who further explained Linda’s 

diagnoses and functional status, the secondary medical conditions she faces as a 

result of prolonged sitting (12 hours) in her wheelchair each day, her need to stand 

numerous times throughout the day without risk of transfer injuries, her inability to 

independently use a separate stander, and the underlying rationale for 

recommending a custom power wheelchair with integrated standing feature as the 

only item of equipment that will address Linda’s complex medical needs.

3 Puglisi 

App. 2, p. 50-52. The DME supplier also explained why certain components could 

not be “removed” from the recommended wheelchair as requested by Molina’s 

outside reviewer. AR 49.

On May 30, 2013, the reviewer provided his “itemized collection of thoughts 

on the equipment in question.” He did not dispute Linda’s medical conditions or 

refute the professional opinions of her medical providers. He acknowledged that 

Linda’s medical providers “offered very detailed benefits of standing” and “they 

note that the member is unable to reap these benefits unless they have the stander 

on their chair... .” AR 118-119.

 

3 There are two general types of standing devices. One is a non-mobile separate stander that 

requires the user to transfer in and out of the device whenever he or she needs to stand. The 

other is a standing feature integrated into a custom wheelchair, which allows for independent 

standing without assistance from care providers and the risk of transfer injuries. 
8

On June 6, 2013, Molina denied Linda’s wheelchair request, stating among 

other things, that the standing feature was neither covered by Medicaid nor 

medically necessary and the seat elevator was not medically necessary. Molina did 

not contest Linda’s medical need to stand throughout the day as recommended by 

the evaluation team. HHSC App. 1.

A Medicaid fair hearing was requested on June 24, 2013, and was held on 

October 30, 2013. AR 267; 19. For the purpose of this hearing, TIRR’s attending 

physician provided an additional letter of medical necessity explaining Linda’s 

medical need for the recommended wheelchair and further advising that “the team 

responsible for conducting Linda’s wheelchair evaluation in February 2013 

continues to support their recommendation for a custom power wheelchair with 

integrated standing feature for Linda.” Linda’s physician also reaffirmed that a 

separate stander would not be effective in addressing the numerous secondary 

medical conditions she faces due to her spinal cord injury. Puglisi App. 6.

In November 2013, HHSC’s hearing officer sustained Molina’s prior 

authorization denial. HHSC App. 2. Linda requested an administrative review of 

this decision pursuant to TEX. GOV’T CODE § 531.019(c) and 1 TEX. ADMIN. CODE

§ 357.703. AR Tab 16, 1-14. On January 14, 2014, an HHSC attorney sustained 

the hearing officer’s decision and upheld Molina’s denial of the recommended 

wheelchair. HHSC App. 3. Having exhausted her administrative remedies, Linda 
9

filed a Petition for Judicial Review on February 7, 2014. CR3-31. While this case 

was pending in the trial court, HHSC informed Linda that, effective May 2014, she 

would be dually eligible for both Medicaid and Medicare. This dual eligibility 

status is known as a Medicaid Qualified Medicare Beneficiary (MQMB). Five 

months later, HHSC filed a motion to dismiss, claiming the case was not ripe 

because of Linda’s dual eligibility. CR 199. The trial court denied this motion in 

November 2014. CR 314. On January 15, 2015, the court reversed HHSC’s 

hearing decision, finding that Linda was entitled to Medicaid prior authorization of 

the recommended wheelchair. CR 348-349.

SUMMARY OF THE ARGUMENT

The trial court correctly determined it had subject matter jurisdiction of this 

case and properly denied HHSC's motion to dismiss. The facts underlying this 

case were ripe when it was filed and continue to be ripe today. No intervening 

event, including Linda’s dual eligibility for Medicaid and Medicare, has rendered 

this case unripe for adjudication.

The trial court properly tailored its decision on the merits to HHSC’s denial 

of Medicaid prior authorization for the recommended wheelchair and remanded the 

case for further action consistent with its decision. The court was not required to 

remand the case to allow HHSC to “change its findings and decision.” Nor was 

the court obligated to defer to HHSC’s post hoc interpretation of agency rules or to 
10

consider “regulatory prerequisites” that were not identified during the 

administrative proceeding as the basis for Molina’s denial of Linda’s prior 

authorization request. 

Molina identified two reasons for its prior authorization denial - - Medicaid 

coverage of the recommended standing feature and Linda’s medical necessity for 

the standing feature and seat elevator. The first is a legal question the trial court 

resolved by finding that “HHSC’s administrative decision fails to comply with the 

controlling federal and state law, and thus, is arbitrary, capricious, and 

unreasonable.” The second is a question of fact the trial court resolved based upon 

the evidence submitted by Linda’s treating medical providers and Molina’s failure 

to refute this evidence. On this issue, the trial court correctly determined that 

HHSC’s decision was not supported by substantial evidence. 

At the fair hearing, Molina had the burden to prove that the reasons for 

denial cited in its notice of adverse action were factually accurate and legally 

correct, but failed to meet this burden. Like Molina, HHSC failed to employ the 

correct test for determining Medicaid coverage of DME and to apply the agency’s 

own medical necessity standards established in rule and policy. Finally, Linda’s 

due process rights as a Medical beneficiary were violated in this case, first by 

Molina’s failure to provide legally sufficient notice, and then by HHSC’s attorney 
11

who based his decision on grounds that were not identified in Molina’s denial 

notice. The trial court’s decision is correct and should be affirmed.

ARGUMENT

A. The Trial Court Correctly Denied HHSC’s Motion to Dismiss.

HHSC’s claim that the trial court lacked subject matter jurisdiction has no 

merit. The court correctly rejected HHSC’s assertion that Linda’s dual eligibility 

for Medicaid and Medicare rendered her case unripe and properly denied the 

agency’s motion to dismiss. While ripeness is a “threshold issue that implicates 

subject matter jurisdiction,” Patterson v. Planned Parenthood of Houston & Se. 

Texas, Inc., 971 S.W.2d 439, 442 (Tex. 1998) citing Mayhew v. Town of 

Sunnyvale, 964 S.W.2d 922, 928 (Tex.1998), there is no question this case was ripe 

when filed and continues to be ripe today. This case does not involve “uncertain or 

contingent future events that may not occur as anticipated or may not occur at all.” 

Waco Indep. Sch. Dist. v. Gibson, 22 S.W.3d 849, 851-52 (Tex. 2000). Rather, the 

facts of this case “have developed sufficiently so that an injury has occurred...”

439 S.W.2d at 442. (citations omitted). This injury – denial of Medicaid prior 

authorization of a power wheelchair with integrated standing feature – occurred 

prior to the filing of this action and continues to date. 

Contrary to HHSC’s claim, Linda’s dual eligibility is not a “significant 

intervening event” that renders her case for Medicaid prior authorization unripe. 
12

HHSC Brief, p.10. It does not matter that “Texas law requires HHSC to analyze 

claims submitted under Medicaid to ensure claims are submitted first under 

Medicare to the extent allowed by law.” (emphasis added) HHSC Brief, p.9. This 

case is not about the payment of claims: it is about the unlawful denial of prior 

authorization of a Medicaid service. Medicare’s primary payor status does not 

dictate any particular order for securing prior authorization of the recommended 

wheelchair.4 

HHSC’s assertion that Linda “is required to avail herself of the CMS prior 

authorization process and procedure in the first instance” is wrong. HHSC Brief, 

p. 11. HHSC does not identify any authority to support this claim and for good 

reason – no such requirement exists in either Medicare or Medicaid law or policy.5 

These are separate programs, enacted with distinct purposes and established with 

different coverage and medical necessity standards.6 

 

4 For dually eligible individuals, Medicare is the primary payor, while Medicaid is secondary. 1 

TEX. ADMIN. CODE § 354.1041. 

5 The DME MAC Supplier Manual cited by HHSC offers no support for the agency's assertion 

that Medicare prior authorization must be obtained “in the first instance.” HHSC App. 11.

6 Numerous courts have recognized the differences between Medicaid and Medicare. See e.g., 

Skubel v. Fuoroli, 113 F.3d 330, 336 (2d Cir. 1997), aff’g 925 F.Supp. 930, 941(D.Conn. 

1996)(rejecting reliance on Medicare regarding scope of Medicaid coverage of home health care 

services); Roe v. Norton, 522 F.2d 928, 933-34n.5 (2d Cir. 1975)(does not infer medical need is 

analogous between Medicare and Medicaid); Rastetter v. Weinberger, 379 F.Supp. 170, 172 

(D.AZ. 1974)(Medicaid is a different law with a different purpose than Medicare); Allegent 

Health v. Amer. Farm Ins., Inc., 656 N.W.2d 906, 911 (Neb. 2003)(Medicare is a program with a 

different purpose and different standards than Medicaid)(citing Evanston Hosp. v. Hauck, 1992 

WL 205900 (N.D. Ill. 1992)(Medicare and Medicaid are entirely separate programs with 

different purposes and standards; federal Medicare enactments do not provide any mandates for 

state Medicaid practices.) aff’d 1 F.3d 540 (7th Cir. 1993), cert. den. 510 U.S. 1091 (1994)). 
13

Importantly, Linda’s MQMB status does not limit the Medicaid services to 

which she is entitled as she remains eligible for the full scope of Medicaid benefits, 

in addition to her Medicare benefits. If an item of DME is not available through 

Medicare, Medicaid remains a source for this service. 1 TEX. ADMIN. CODE §§

354.1041(2)(B); 355.8021(b)(2-3). Moreover, Linda’s MQMB status does not 

alter the fact that she is required to follow the same process for obtaining a custom 

power wheelchair through Medicaid as all other beneficiaries. A description of 

this process, which consists of four sequential steps, demonstrates the ripeness of 

Linda’s case. 1 TEX. ADMIN. CODE § 354.1040. 

First, a Medicaid beneficiary must undergo a clinical assessment by a 

licensed occupational or physical therapist and a qualified rehabilitation 

professional (QRP). Next, a Medicaid-enrolled DME supplier must submit a prior 

authorization request, including the clinical assessment, a physician’s attestation of 

medical necessity, a detailed description of the wheeled mobility system and all 

medically necessary components or accessories, and any other documentation 

required to explain the medical necessity of the requested equipment. 1 TEX.

ADMIN. CODE § 354.1040(d)(3). If prior authorization is granted, the DME 

supplier orders and delivers the authorized wheelchair to the beneficiary. Once the 

wheelchair is delivered, the DME supplier completes the final step – submission of 

the claim for payment. 1 TEX. ADMIN. CODE § 354.1040(g). In instances where “a 
14

third party health insurer is identified, [suppliers] are required to bill the third party 

health insurer before submitting a claim for payment to the Commission...”7 1 

TEX. ADMIN. CODE § 354.2321(b). 

Here, HHSC’s ripeness argument erroneously conflates the prior 

authorization step in this process, which occurs before the wheelchair is provided, 

with the final step, payment of the supplier’s claim. This argument is not new. In a 

similar administrative case, New York Medicaid refused to process the DME prior 

authorization request of a dually-eligible beneficiary claiming she “was required to 

explore Medicare approval first because [Medicaid] is the payor of last resort.” 

Rejecting this argument, the Commissioner explained: 

The issue here is a request for prior approval, not a request for 

payment. Although the Medical Assistance program is the payor of 

last resort, the question of payment is not relevant to the issue of prior 

approval . . . [t]he Appellant is entitled to have the Agency determine 

whether the walker is medically necessary, which is a separate and 

distinct question from the amount of Medical Assistance payment, if 

any.

Puglisi App. 7.

Similarly, Connecticut settled a lawsuit challenging this same practice by the 

state’s Medicaid program, clarifying in statute that the DME prior authorization 

 

7

“The Commission may be billed for the difference between the amount paid by the third party 

health insurer and the Medicaid payable amount...” 1 TEX. ADMIN. CODE § 354.2321(f).
15

process must be available to dually eligible beneficiaries.8 As explained in Conn. 

Gen. Stat. Sec. 17b-281a, “[a]ccess to [the DME preauthorization process] shall 

not be denied to a recipient on the basis that a Medicare determination has not been 

made prior to the submission of a request for preauthorization to the 

commissioner.”

Regardless of Linda’s MQMB status, the facts underlying HHSC’s unlawful 

denial of Medicaid prior authorization remain ripe. Until HHSC authorizes the 

recommended wheelchair, Linda is unable to proceed any further in the agency’s 

four-step process for obtaining a custom power wheelchair. The DME supplier 

cannot deliver the wheelchair or request payment first from Medicare, the primary 

payor, and then from Medicaid, the secondary one. 

On the merits of the case, the trial court correctly found that HHSC’s 

decision sustaining Molina’s prior authorization denial failed “to comply with 

controlling and applicable federal and state law, and thus, is arbitrary, capricious, 

and unreasonable.” The court properly limited its decision to this issue, stating that

“[b]ecause this DME item must [be] prior authorized from Texas Medicaid, the 

Court reverses the administrative decision of the Texas Health and Human 

Services Commission on [the] prior authorization [question] presented.” HHSC 

 

8 Frank v. Thomas, No. 3:98CV00306(GLG), U.S. Dist. Ct., D. Conn. 1998 (class action brought 

by an individual with a disability who was denied Medicaid prior authorization of a standing 

wheelchair because of her dual eligibility status. 
16

App. 10. Once HHSC issues Medicaid prior authorization, the wheelchair can be 

provided to Linda. Only then can the DME supplier request payment, first through 

Medicare and then through Medicaid. 

In determining the ripeness of a case, courts may consider “the importance 

of the interest advanced [and] the extent of the injury...” Perry v. Del Rio, 66 

S.W.3d 239, 251-52 (Tex. 2001), citing 13 Charles Alan Wright, Arthur R. Miller, 

& Edward H. Cooper, FEDERAL PRACTICE AND PROCEDURE § 3532.1, at 

130 (2d ed.1984). Here, the injury caused by HHSC's erroneous hearing decision 

is a harsh one. Linda first requested prior authorization of the recommended 

wheelchair in April 2013. During this time, she has had to rely upon a loaner 

wheelchair that is not customized to meet her needs. Requiring her to begin the 

process again, starting with a new evaluation and a new request for Medicaid prior 

authorization, would subject her to further delay during which time she will not 

have access to the medically necessary wheelchair she requires to address her 

many medical conditions. The facts underlying this case are ripe and the trial 

court's decision denying HHSC's motion to dismiss should be affirmed.

B. The Trial Court Correctly Reversed and Remanded the Case to HHSC 

for Further Proceedings Consistent with Its Decision.

HHSC takes issue with the trial court’s reversal of the agency’s hearing 

decision and remand for agency action consistent with this decision. According to 

HSHC, the “REVERSAL component of the order [ ] is in conflict with the 
17

‘REMAND’ component.” HHSC Brief, p. 12. This is incorrect. The trial court 

was careful to consider and decide the central issue before it - whether HHSC 

erroneously sustained Molina’s denial of Linda’s prior authorization request. 

Having properly found that HHSC’s hearing decision was “arbitrary, capricious, 

and unreasonable” and “unsupported by substantial evidence,” the trial court 

correctly remanded the case for the agency to issue Medicaid prior authorization of 

the recommended wheelchair. 

HHSC’s claim that the agency should have the opportunity to take additional 

evidence on remand is wrong. HHSC Brief, p.13. There is no dispute that Linda 

became eligible for Medicare in May 2014 or that she is entitled to the full scope 

of benefits available through Medicaid and Medicare. Moreover, there is no law or 

policy that requires Medicare authorization of DME to be requested before seeking 

prior authorization from Medicaid. Finally, there is no question that once the 

recommended wheelchair has been delivered to Linda, the DME supplier must first 

bill Medicare before submitting a claim to Medicaid.

Linda’s MQMB status has no bearing on her right to Medicaid prior 

authorization of the requested wheelchair. Thus, the trial court correctly rejected 

HHSC’s request to remand the case so it could “change its findings and decision.” 

HHSC’s Brief, p.13. There are no new facts to be determined, no new legal 

requirements to be applied in this case. Given the express language of the court’s 
18

order, HHSC’s assertion that “the trial court failed to consider Puglisi’s dual 

eligible status in the context of the suit for judicial review” has no merit. HHSC 

Brief, p. 12. 

C. Deference is Not Owed to HHSC’s Post-Hoc Interpretation of Agency 

Rules.

HHSC next maintains the trial court failed to defer to the agency’s 

interpretation of 1 TEX. ADMIN. CODE §§ 354.1039(a) and 354.1039(a)(4)(a) in 

reversing its hearing decision. Again, this argument has no merit. Neither of these 

rules were identified by Molina as the legal basis for denying Linda’s prior 

authorization request. HHSC App. 1. Yet, federal Medicaid regulations require the 

Medicaid agency or its designee to identify the “specific regulations that 

support...the action” in its notice of adverse action. 42 C.F.R. § 431.210(c). 

Similarly, neither HHSC’s hearing officer nor reviewing attorney mentioned these 

rules, let alone cited them as the legal basis for sustaining Molina’s prior 

authorization denial. HHSC App. 2, 3. HHSC has no credible complaint that the 

trial court failed to defer to the agency’s interpretation of rules that were never 

identified as the basis for HHSC’s hearing decision.

This Court’s decision in Sw. Pharmacy Solutions, Inc. v. Texas Health & 

Human Servs. Comm’n, 408 S.W.3d 549 (Tex. App. 2013), review denied (Nov. 

22, 2013) does not support HHSC’s position. The present case is not about 

construction of a statute or rule that expressly excludes wheelchair standing 
19

features as no such law exists. To the contrary, applicable statute and rules 

specifically support Medicaid coverage of this specialized component. It is only 

TMHP policy that states otherwise, in conflict with Texas Medicaid law. As this 

Court explained, “an agency’s interpretation of a statute it is charged with 

enforcing is entitled to ‘serious consideration,’ so long as the construction is 

reasonable and does not conflict with the statute’s language..." "We defer to an 

agency’s interpretation of its own rules unless it is plainly erroneous or contradicts 

the text of the rule or underlying statute.” (citations omitted) Id. at 557-58. See 

also Tarrant Appraisal Dist. v. Moore, 845 S.W.2d 820, 823, (Tex. 1993) citing

Stanford v. Butler, 181 S.W.2d 269, 273 (Tex.1944).

Here, the agency’s post hoc interpretation of the above-cited rules 

contradicts the plain language of TEX. HUM. RES. CODE § 32.0425 and 1 TEX.

ADMIN. CODE § 354.1040, which broadly define custom wheelchairs to include 

other complex or specialized components. HHSC’s claim that 1 TEX. ADMIN.

CODE § 354.1039(a) allows the agency to exclude complex or specialized 

wheelchair components is wrong and is not entitled to “serious consideration” or 

deference by any court. 

The same is true about HHSC’s interpretation of 1 TEX. ADMIN. CODE §

354.1039(a)(4)(A), which requires, among other things, that DME be medically 

necessary. Molina did not apply either medical necessity standard established in 
20

Medicaid rule and policy in this case. AR 326, Response to Interrogatory No. 6. 

Nor did HHSC’s hearing officer and reviewing attorney. HHSC App. 2, 3. 

Nowhere does HHSC determine whether the recommended power wheelchair with 

all prescribed components is required “to correct or ameliorate [Linda’s] disability, 

medical condition, or illness, 2013 TMPPM DME Handbook §2.2.2, or will “serve 

a specific medical purpose.” 1 TEX. ADMIN. CODE § 354.1039(a)(4)(D). The trial 

court’s judgment that HHSC’s hearing decision is arbitrary and capricious is fully 

supported by the administrative record in this case.

D. The Trial Court Correctly Determined that HHSC’s Hearing Decision 

Fails to Comply with Medicaid Law. 

HHSC also defends its hearing decision by claiming it complies with 1 TEX.

ADMIN. CODE §§ 354.1031, .1035, .1039 and .1040 but fails to explain how this is 

so. In fact, there is no credible support for this claim. The first rule, 1 TEX.

ADMIN. CODE § 354.1031(b)(12), defines DME and governs whether an item of 

medical equipment is “covered” by Texas Medicaid. As explained by CMS, 

medical equipment satisfying the state’s DME definition is “to be provided to 

individuals (of any age) meeting the State’s medical necessity criteria." Puglisi 

App. 1. Yet, neither Molina nor HHSC applied the state's DME definition to the 

wheelchair standing feature to determine whether it is covered through the home 

health benefit. HHSC App. 1, 2, 3.
21

Next, 1 TEX. ADMIN. CODE § 354.1035 sets out the qualifications for home 

health services, only two of which - coverage and medical necessity - were 

identified as the basis for Molina’s denial of Linda’s prior authorization request. 

HHSC’s argument to the contrary is incorrect. 

Finally, both 1 TEX. ADMIN. CODE §§ 354.1039 and .1040 fully support 

Medicaid coverage of the requested wheelchair and its components, not HHSC’s 

finding of non-coverage. These rules define custom wheelchairs available through 

Texas Medicaid to include “medically justified equipment” and “complex or 

specialized components.” The application of these rules to the requested 

wheelchair standing feature establishes its coverage as DME. HHSC’s decision to 

the contrary is arbitrary and capricious. See Rodriguez v. Serv. Lloyds Ins. Co.,

997 S.W.2d 248, 255 (Tex. 1999) (stating an agency’s action will be reversed as 

arbitrary and capricious when the agency fails to follow “the clear, unambiguous 

language of its own regulation.”)

HHSC’s claim that Linda failed to satisfy the necessary prerequisites for 

prior authorization of DME is wholly unsupported by the administrative record. 

Moreover, the agency’s suggestion that Linda is not eligible for the requested 

wheelchair because “the home health agency must obtain prior authorization”

completely misses the point of this case. From the outset, Linda has challenged 

Molina’s denial of prior authorization for the custom wheelchair recommended by 
22

her treating medical providers. The trial court correctly found Linda has 

established her right to Medicaid prior authorization of this wheelchair.

E. The Trial Court Correctly Determined that HHSC’s Hearing Decision is 

Arbitrary, Capricious, Unreasonable and Unsupported by Substantial 

Evidence.

1. The Trial Court Properly Addressed the Two Reasons Molina Denied 

Linda Puglisi’s Prior Authorization Request.

Molina’s denial of Linda’s prior authorization request for a custom power 

wheelchair with integrated standing feature raised two issues. HHSC App. 1. The 

first - Medicaid coverage of the standing feature - is a legal question the trial court 

correctly resolved by finding that “HHSC’s administrative decision fails to comply 

with the controlling federal and state law, and thus, is arbitrary, capricious, and 

unreasonable.” The second – Linda’s medical need for the recommended 

wheelchair - is a question of fact the trial court resolved based upon the probative 

evidence submitted by Linda’s medical providers and Molina’s failure to refute 

this evidence. On this issue, the trial court correctly determined that HHSC’s 

decision was not supported by substantial evidence. HHSC App. 10, CR 348-349.

On appeal, HHSC claims the trial court failed to decide the “salient question 

[ ] whether Puglisi is required to satisfy all or only part of the regulatory 

prerequisites necessary to acquire the requested DME.” HHSC’s Brief, p. 17. This 

is wrong. The trial court correctly decided the two issues raised by Molina in its 
23

denial notice, addressed by Molina at the hearing, and decided in the agency’s 

hearing decision. 

HHSC’s description of additional “regulatory prerequisites” is also wrong. 

Linda was not required to establish, nor was the trial court required to determine, 

that the recommended wheelchair is “reimbursable DME.” As explained in 

Detgen v. Janek, 945 F. Supp. 2d 746, 758 (N.D. Tex. 2013), “claimants ought not 

be required to assure HHSC during the prior authorization process that [federal 

reimbursement] will be available for items they request.” HHSC App. 12. This is 

particularly true given that CMS directly informed HHSC that “federal 

reimbursement is available to the state to the extent that [an] item is determined to 

be covered.” Puglisi App. 1. Simply put, Medicaid reimbursement is available for 

medical equipment that meets the state’s definition of DME.9 

HHSC’s assertion that the trial court failed to decide if there was adequate 

documentation of “appropriateness” is equally unpersuasive. Molina did not deny 

Linda’s prior authorization request on this basis and HHSC did not address 

“appropriateness” in its decision. Clearly, the trial court was not obliged to do so 

either.

 

9 Linda’s undisputed evidence established that integrated standing features have been reimbursed 

by Texas Medicaid under the miscellaneous DME code (E1399) and the code for wheelchair 

standing features (E2301). See Declaration of Britt Sitzes, AR 289-290, ¶4; Declaration of 

Nancy Rice, AR 291-292, ¶¶ 5&6.
24

Finally, HHSC’s claim that the trial court failed to consider whether Linda 

“had received prior authorization” once again ignores the fact that Linda's

entitlement to Medicaid prior authorization of the recommended wheelchair was 

the central issue before the trial court. It goes without saying that Linda had not 

received Medicaid prior authorization before filing this case in the district court.

HHSC’s claim that the trial court erred by “discarding” these additional

“regulatory prerequisites” has no merit. 

2. HHSC Failed to Address Linda Puglisi's Medical Need for a Custom 

Power Wheelchair with Integrated Standing Feature.

HHSC failed to apply its own medical necessity standards to determine 

whether the evidence submitted by Linda’s medical providers established that a 

custom power wheelchair with integrated standing feature will correct or 

ameliorate her disability or medical condition or will serve a specific medical 

purpose for her. 2013 TMPPM DME Handbook, §2.2.2; 1 TEX. ADMIN. CODE 

§354.1039(a)(4)(D). To be clear, HHSC made no decision whether the standing 

feature of the recommended wheelchair is medically necessary for Linda even 

though standing is the essential wheelchair function she requires to address her 

numerous medical conditions caused or exacerbated by prolonged sitting day in 

and day out. The agency failed to address this critical issue, and instead, limited its 

medical necessity determination to the wheelchair base and seat elevator, two parts 

of the wheelchair that are required to operate the standing function of the 
25

recommended wheelchair. This fundamental error, and others, justified the trial 

court's reversal of HHSC’s decision

The administrative record demonstrates that Linda’s well-qualified health 

care providers submitted ample evidence of her medical need for the recommended 

wheelchair.10 This documentation established that Linda suffers from numerous 

medical conditions secondary to quadriplegia and prolonged sitting (12 hours) in a 

wheelchair every day. These conditions include osteopenia and an increased risk 

for bone density loss, compromised soft tissue integrity, impaired integumentary 

sensation and respiratory function, neurogenic bowel, and neurological pain. 

Puglisi App. 2, p.50, ¶2. As a result, Linda has a medical need to stand numerous 

times throughout the day to address the adverse effects of these serious medical 

conditions. According to Linda’s physician:

This increased frequency of standing will maximize the medical 

benefits of standing, including but not limited to, providing complete 

pressure relief from prolonged sitting, maintaining bone density, 

 

10 In the Medicaid program, treating medical professionals play a central role in determining 

their patient's medical needs. As described in the legislative history of the Medicaid Act:

The committee’s bill provides that the physician is to be the key figure in 

determining utilization of health services - and provides that it is a physician who 

is to decide upon admission to a hospital, order tests, drugs and treatments, and 

determine the length of stay. For this reason the bill would require that payment 

could be made only if a physician certifies to the medical necessity of the services 

furnished. 

S.Rep. No. 404, 89th Cong., 1St Sess., reprinted in 1965 U.S.C.C.A.N. 1943. See Weaver v. 

Reagan, 886 F. 2d 194, 200 (8th Cir. 1989), (“[t]he Medicaid statute and regulatory scheme 

create a presumption in favor of the medical judgment of the attending physician in determining 

the medical necessity of treatment.) 
26

decreasing muscle tone, improving circulation, increasing respiratory 

function, and maintaining/improving range of motion to hips, knees, 

and ankles. Reducing or eliminating the occurrence of these medical 

complications from prolonged sitting will help Linda maintain her 

health and well-being and decrease the associated costs of her future 

medical care. Puglisi App. 2, p.51, ¶4.

Linda’s physician further made clear that “[w]ith the recommended 

wheelchair, Linda will be able to stand more often and for shorter periods, making 

each standing opportunity more effective in preventing bone loss and promoting 

bone density.” Puglisi App. 2, p.51, ¶3. Her occupational therapist also explained 

that the recommended wheelchair will enhance Linda’s “biomechanical alignment 

throughout the entire body on a daily basis, which helps to prevent further impact 

of spasticity on joints in upright postures.” Puglisi App. 3, p.69, ¶1. 

Additionally, Linda’s physician described why a separate stander will not 

meet her medical needs:

Unlike a separate stander that would require Linda to have caregiver 

assistance each time she uses the device, the recommended wheelchair 

will allow Linda to independently stand as often as possible and in 

any location, whether at home or in the community. Research 

demonstrates that short, frequent standing is more effective in 

improving bone density than one long standing episode. With the 

recommended wheelchair, Linda will be able to stand more often and 

for shorter periods, making each standing opportunity more effective 

in preventing bone loss and promoting bone density. 

Puglisi App.2, p.51, ¶ 3.

Finally, Linda’s evidence established that the recommended wheelchair 

requires several components, including tilt and recline, center mount articulating 
27

elevating leg rests, a stand and drive leg rest assembly, and seat elevation, for the 

standing feature to function. As explained, the standing system is not operational

without these components, all of which must be accommodated by a Group 4 

wheelchair base. Puglisi App.2, p. 51, ¶1; App. 5, p. 293, ¶5. According to Linda’s 

physician, 

[T]he specific wheelchair recommended for Linda - Permobil 

C500VS - requires a Group 4 base, with seat elevation and integrated 

standing feature to permit the user to independently stand. As such, 

these components cannot be “removed” from the prior authorization 

request without substantially changing the nature of the wheelchair.

At the fair hearing, Molina failed to prove the accuracy of the medical 

necessity determinations identified in its denial notice.11 Nor did Molina offer any

evidence that its medical necessity decision was made by qualified medical 

professionals. While Molina’s denial notice suggests that a physician made this 

decision, HHSC App. 1, their evidence established that Linda's wheelchair request 

was sent to a third-party entity to determine medical need. HHSC App. 2, Finding 

of Fact 5. This third-party reviewer was not a physician, an occupational therapist 

or a physical therapist.12 AR 118. 

Molina also was clear it did not apply Texas Medicaid’s medical necessity 

standards to Linda’s prior authorization request. As they explained: 

 

11 Pursuant to 1 TEX. ADMIN. CODE § 357.9, Molina had the burden to prove by a preponderance 

of the evidence that the reasons for denial identified in its notice of adverse action were factually 

accurate and legally correct. 

12 Texas Medicaid requires that wheelchair evaluations be conducted by a licensed physical or 

occupational therapist or physician. 2015 TMPPM §2.2.15.10. 
28

Molina utilizes the standards set forth by the National Committee for 

Quality Assurance (NCQA). Accordingly, the definition of “Medical 

Necessity” as set by NCQA as follows:

Determinations on decisions that are (or which could be considered to 

be) covered benefits, including determinations defined by the 

organization; hospitalization and emergency services listed in the 

Certificate of Coverage or Summary of Benefits and care or service 

that could be considered either covered or non-covered depending on 

the circumstances.13

AR 326, Response to Interrogatory No. 6.

Molina’s denial contained several erroneous statements. As to the standing 

feature, Molina claimed it “is not considered medically necessary because driving 

standing up is not a medical necessity.” HHSC App.1. However, Molina offered 

no credible evidence to support this statement. In fact, this assertion completely 

misconstrues the purpose and function of the wheelchair standing feature. Linda’s 

medical professionals did not recommend this feature so Linda could drive her 

wheelchair while standing.14 They recommended this feature so that Linda can 

independently stand throughout the day to address the many medical conditions 

she experiences as a result of prolonged sitting. 

As to the seat elevator, Molina claimed “the documentation submitted did 

not indicate how the power seat elevator system would promote independence.” 

 

13 Federal Medicaid law prohibits managed care organizations from applying a more restrictive 

medical necessity standard than the one established in “State statutes and regulations, the State 

Plan, and other State policy and procedures.” 42 C.F.R. § 438.210(a)(4)(i). 

14 Linda’s evidence established that “[t]he standing feature of the Permobil C500 can be used 

while the wheelchair is stationary or while moving at low speeds.” See Affidavit of Amy 

Morgan, PT. Puglisi App. 5, ¶10. 
29

HHSC App.1. This statement was based on a TMHP policy governing power seat 

elevators required to facilitate independent transfers. TMMPM §2.2.15.15. HHSC 

App. 5. However, this policy has no relevance to Linda’s medical need for a 

standing wheelchair as the seat elevator was not requested for transferring. It was 

requested because the standing feature of the recommended wheelchair will not 

operate without it. 

Importantly, Molina did not refute the medical evidence submitted by 

Linda’s medical providers or dispute their professional opinions that frequent daily 

standing is required to address her numerous medical conditions. In fact, Molina 

conceded Linda’s medical need to stand by suggesting she obtain a separate 

standing device.15 HHSC App. 2, Finding of Fact 10. 

Moreover, Molina did not dispute the evidence establishing that Linda 

cannot access a separate stander on her own due to the severity of her disability 

and that she lacks sufficient personal care providers to assist her with using such 

equipment numerous times throughout the day. Puglisi App. 2, p. 50, ¶3; HHSC 

App. 2, Finding of Fact 10. Even Molina’s third-party reviewer did not conclude 

that a separate stander was sufficient to meet Linda’s needs. Rather, he 

acknowledged the opinion of Linda’s medical providers “that the member is unable 

 

15 According to Texas Medicaid policy, separate standers are approved to address medical needs 

like those experienced by Linda, e.g. “improve digestion, increase muscle strength, decrease 

contractures, increase bone density, and minimize decalcification (this list is not all inclusive).” 

TMPPM DME Handbook, §2.2.15.22.1.
30

to reap [the] benefits [of standing] unless they have the stander on their chair...” 

AR 118, ¶4. 

Like Molina, HHSC failed to apply the agency’s medical necessity standards 

established in Texas Medicaid rule and policy. HHSC did not determine whether 

the recommended custom power wheelchair with integrated standing feature will 

correct or ameliorate the medical conditions documented by Linda’s medical 

professionals or will serve a specific medical purpose for her. HHSC did not 

address Molina’s assertion that “driving while standing is not a medical necessity”

and ultimately, made no decision whether the standing feature is medically 

necessary for Linda. It is this essential feature, however, that was recommended 

by Linda’s medical providers to address her numerous medical conditions caused 

or exacerbated by prolonged sitting day in and day out. 

HHSC also erroneously determined that a seat elevator is not medically 

necessary because it “will not facilitate independent transfers to and from the 

wheelchair for Appellant.” HHSC’s App. 2. Again, this determination ignores the 

critical fact that a seat elevator was included in the prior authorization request 

because the recommended wheelchair will not stand without it. Certainly, Molina 

made no attempt to disprove Linda’s evidence that the seat elevator ensures “the 

anterior stability of the wheelchair by allowing the caster wheels to be in contact 

with the ground” when standing. Puglisi App. 5, ¶ 5.
31

Although HHSC’s hearing officer limited his medical necessity 

determination to the seat elevation device, HHSC’s reviewing attorney went one 

step further. Completely ignoring Linda’s medical need for the standing feature, 

he determined that Linda did not qualify for the Group 4 base on the recommended 

wheelchair. HHSC App. 3. While acknowledging that “the integrated standing 

feature and seat elevation system are not available with the Group 3 custom power 

wheelchair, HHSC App. 3, Finding of Fact 7, he ignored the fact that Molina did 

not deny prior authorization of the Group 4 base on the basis of medically 

necessity. Faced with insufficient medical evidence to support Molina’s denial, 

HHSC’s reviewing attorney fashioned a new rationale for the denial, in violation of 

Linda’s due process right to timely and adequate notice of all reasons for the 

denial, with supporting legal citation, prior to the fair hearing. 42 C.F.R §§ 

431.210(b-c). 

The bottom line is that the administrative record contains no credible 

evidence refuting the professional opinions of Linda’s medical providers that a 

custom wheelchair with integrated standing feature will address the “numerous 

secondary medical conditions Linda faces due to her spinal cord injury” and that “a 

separate stander will not provide the same medical benefits for Linda.” Puglisi 

Apps. 2, 3, 6. 
32

In this appeal, HHSC’s defense of its hearing decision begins with the 

erroneous assertion that Linda was required to prove her medical need for a Group 

4 wheelchair base. This is incorrect. As explained above, this claim was not part 

of Molina’s medical necessity denial, but rather, was the post hoc invention of 

HHSC’s reviewing attorney. HHSC App 3. HHSC cannot ignore the fact that 

Molina’s evidence wholly failed to refute Linda’s medical need to stand and her 

inability to use a separate stander and then concoct a new basis for denial after the 

fair hearing. Molina’s denial notice does not cite TMPPM 2.2.14.12.5 as support 

for its decision and HHSC’s argument concerning this policy has no bearing on the 

outcome of this case. Molina recognized that the Group 4 wheelchair base “was 

requested in order to accommodate the Power Stand and Drive function.” HHSC 

App. 1. And as Molina’s outside reviewer noted, the requested wheelchair only 

comes with a Group 4 base and the difference between a Group 3 and 4 base is not 

a question of medical necessity. AR 118. 

HHSC’s assertion that Linda was required to demonstrate that a Group 4 

wheelchair base is medically necessary, i.e. will correct or ameliorate her 

disability, condition, or illness, is nonsensical. The recommended wheelchair 

requires many components to be operational and there is no requirement that 

medical necessity be demonstrated for each and every one. The undisputed 

evidence established that several identified components, as well as the Group 4 
33

wheelchair base, are required to operate the standing feature of the wheelchair.

Puglisi App. 5. 

HHSC’s defense of its medical necessity decision concerning the seat 

elevation system fails for the same reason. It is undisputed that the power seat 

elevator, like the Group 4 wheelchair base, is required to operate the standing 

feature of the recommended wheelchair. HHSC cannot deny Linda’s medical need 

for a custom power wheelchair with integrated standing feature because she lacks 

the functional ability to perform “uphill transfers.” The agency’s reliance upon 

TMPPM 2.2.14.15 to deny the recommended wheelchair wholly ignores the fact 

that Linda has a medical need to stand throughout the day and the recommended 

wheelchair is the only item of DME that will meet her medical needs.16 

Moreover, HHSC’s argument concerning medical necessity for a seat 

elevator creates an impermissible distinction between Medicaid beneficiaries based 

on the severity of their disabilities. As such, individuals who have a medical need 

to stand and who can perform independent transfers, “particularly uphill transfers,”

can obtain a standing wheelchair, while those with more severe disabilities who 

have the same medical need to stand but lack the functional ability to self-transfer, 

cannot. Under HHSC’s analysis, individuals with quadriplegia would never qualify 

 

16 HHSC suggests Linda’s documentation “did not demonstrate how the power seat elevator 

system would promote independence.” This is inaccurate. Linda’s physician specifically advised 

that “the specific wheelchair recommended for Linda - Permobil C500VS - requires a Group 4 

base, with seat elevation and integrated standing feature to permit the user to independently

stand.” (emphasis added) Puglisi App. 2, ¶1.
34

for a wheelchair with integrated standing feature due to the severity of their 

disabilities and their functional inability to self-transfer. While this distinction 

between Medicaid beneficiaries makes no medical sense, it also violates the 

Medicaid Act’s comparability requirement and its prohibition against diagnosisbased decision making.17

 HHSC cannot deny eligibility for standing wheelchairs 

based upon severity of disability when there is no medical rationale to support this 

distinction.

HHSC’s medical necessity arguments concerning the Group 4 power base 

and seat elevator are a futile attempt to evade the fact that its hearing decision 

failed to address Linda’s medical need for a custom power wheelchair with 

integrated standing feature. The trial court correctly determined that HHSC’s 

hearing decision is unsupported by substantial evidence. 

3. HHSC Failed to Employ the Correct Test for Determining Medicaid 

Coverage of DME.

Medical equipment is covered through Medicaid’s home health benefit when 

the item fits within the state's DME definition. Puglisi App. 1. HHSC concedes 

this is the proper test for DME coverage, HHSC Brief, p.30, but ignores the fact 

that both its hearing officer and reviewing attorney failed to apply this test to the 

recommended wheelchair standing feature. Instead, they erroneously presumed 

 

17 42 U.S.C. § 1396a(a)(10)(B); 42 C.F.R. § 440.240(b); See Lankford v. Sherman, 451 F.3d 496 

(8th Cir. 2006) (comparability requirement violated when state covers items of DME for certain 

individuals with disabilities but not for others.)
35

non-coverage based upon TMHP’s policy exclusion of standing features and 

sustained Molina’s coverage determination on this basis. HHSC App. 2, 3.

Contrary to HHSC’s claim, Linda has never suggested that Medicaid 

coverage of the recommended standing feature should be “assumed.” Instead, she 

maintains that HHSC cannot lawfully apply TMHP’s presumption of non-coverage 

as it did in this case.18 Here, there is no question the standing feature meets the 

state’s DME definitions and its definition of wheeled mobility systems.

HHSC relies upon Detgen v. Janek, 752 F. 3d 627 (5th Circuit 2014), to 

defend its failure to correctly determine Medicaid coverage of the recommended 

wheelchair component, however, this reliance is misplaced. Detgen upheld the 

state’s exclusion of ceiling lifts, finding that a state can choose “by definition” to 

exclude ceiling lifts from coverage. Id. at 632. Here, the opposite is true and 

necessarily compels a different outcome. The Texas Legislature chose to define 

custom wheelchairs to include wheelchairs with complex or specialized

components like the standing feature at issue in this case. TEX. HUM. RES. CODE § 

32.0425. 

Next, Detgen found the exclusion of ceiling lifts to be “reasonable” because 

of the availability of “more cost effective alternatives.” According to the Court, “a 

 

18 HHSC acknowledges that CMS reminded the agency of this specific test for DME coverage, 

yet inexplicably claims that TMHP’s exclusion of wheelchair standing features complies with 

federal policy. HHSC Brief, p. 30. HHSC makes no attempt to explain the contradiction 

between these two statements.
36

categorical exclusion based upon the availability of cost effective alternatives 

cannot mean that the state has denied a medically necessary device.” Id. at 632. 

Here, however, HHSC’s exclusion of wheelchair standing features means the state 

has denied Linda a medically necessary device for which there is no alternative 

that will meet her medical needs. It is undisputed that Linda cannot transfer to a 

separate stander numerous times each day to correct or ameliorate her many 

medical conditions caused by prolonged sitting.

Finally, Detgen is not dispositive in Linda’s case because this decision is 

wrong. It is an outlier among dozens of case rejecting states’ efforts to exclude a 

wide array of DME items and uniformly holding such DME exclusions to be 

unlawful.19 As explained in Lankford v. Sherman, 451 F.3d 496, 511 (8th Cir. 

 

19 See e.g., Alvarez v. Betlach, 572 F. App’x 519 (9th Cir.) cert. denied, 135 S. Ct. 870 

(2014)(rejecting Arizona Medicaid’s exclusion of incontinence briefs); Lankford v. Sherman, 

451 F.3d 496 (8th Cir. 2006) (rejecting Missouri Medicaid’s restrictions on DME coverage); 

Fred C. v. Texas Health & Human Services Comm’n, 988 F.Supp. 1032 (W.D.Tx. 1997), 

affirmed per curiam 167 F.3d 537 (5th Cir. 1998) (requiring coverage of augmentative 

communication devices as DME and prosthetic devices); Meyers v. Reagen, 776 F.2d 241 (8th 

Cir. 1985)(requiring coverage of augmentative communication devices that fit within the scope 

of the equipment included in Medicaid’s speech-language pathology service); Davis v. Shah, No. 

12-CV-6134 CJS, 2012 WL 1574944, (W.D.N.Y. May 3, 2012) (rejecting exclusion of 

orthopedic footwear and compression stocking as DME for certain beneficiaries) Hiltibran v. 

Levy 793 F.Supp.2d 1108 (W.D. Mo. 2011)(granting preliminary injunction requiring coverage 

of incontinence aids for adults as medical equipment); Jasset v. R.I. Dept. of Hum. Serv., 2006 

WL 2169891 at * 5 (R.I. Super. July 31, 2006) (citing Bristol v. R.I. Dept. of Hum. Serv., 1997 

WL 839884, at *5 (R.I. Super. Jan. 30, 1997)(prohibiting intent to go to work or school as a 

coverage criterion for a wheelchair because neither is related to medical necessity)); Blue v. 

Bonta, 99 Cal.App. 4th 980, 121 Cal.Rptr.2d 483 (Cal App. 2002) (requiring coverage of 

stairway elevator based on Medi-Cal DME definition); T.L. v. Colorado Dept. of Health Care 

Policy & Fin., 42 P.2d 63 (Colo. App. 2002) (prohibiting express exclusion of whirlpool bath 

from consideration as DME and without consideration of medical need); Will T. v. Taylor, 465 

F.Supp.2d 1267 (N.D. Ga. 2000)(requiring coverage of speech generating devices as DME, 
37

2006), “[a] state’s failure to provide Medicaid coverage for non-experimental, 

medically necessary services within a covered Medicaid category is both per se 

unreasonable and inconsistent with the stated goals of Medicaid.” 

Ignoring these many cases, the Detgen court reached a conclusion that does 

not square with federal Medicaid case law or policy. This is particularly true 

concerning its interpretation of the DeSario Letter. HHSC App. 6. Contrary to the 

plain language of this federal guidance, the Court concluded that states are 

authorized to maintain a "never approved" list of DME. Id. at 632-633. If this were 

correct, the Second Circuit’s decision in DeSario v. Thomas upholding the state's 

list of DME exclusions would still be good law. 139 F.3d 80 (2d Cir. 1998). But it 

is not good law precisely because CMS clarified that exclusions of medical 

equipment meeting the state’s definition of DME violate the Medicaid Act's 

 

prosthetic devices and equipment under the speech-language pathology benefit); Bell v. Agency 

for Health Care Admin., 768 So.2d 1203 (FL. App. 2000)(requiring coverage and provision of 

insulin pumps when medically necessary); Johnson v. Minn. Dept. of Human Serv., 565 N.W.2d 

453, 456 (Minn. App. 1997) (requiring coverage of a stand-up wheelchair to meet recipient’s 

specific medical needs); Davis v. Shrader, 687 N.E.2d 370 (Ind. App. 1997) (requiring coverage 

of orthopedic shoes; precluding use of irrebuttable presumptions against coverage of specific 

types of treatment within covered services); Ohlson v. Weil, 953 P.2d 939 (Colo. App. 

1997)(requiring coverage of body brace that meets Medicaid’s DME definition); Brisson v. 

Dep’t of Social Welf., 702 A.2d 405 (VT. 1997)(prohibiting exclusion of closed circuit television 

because it meets Medicaid’s definition of eyeglasses); Hunter v. Chiles, 944 F.Supp. 914 (S.D. 

Fl. 1996)(requiring coverage of speech generating devices as DME); Myers v. State of 

Mississippi 3:95 CV 185 LN (Slip Op. S.D. Miss. 1995)(requiring coverage of speech generating 

devices as DME); Bowers v. Thompson; No. 89-2-00553-8 Stipulation & Agreement & Consent 

Order (Wash. Super. Ct. Thurston County Oct. 15, 1990) (class action consent decree 

establishing medical necessity as decision-making standard for durable medical equipment, 

prosthetic devices and non-durable medical supplies); Ledet v. Fischer, 638 F. Supp. 1288, 1291 

(M.D. La. 1986) (requiring coverage of eyeglasses regardless of diagnosis); Baker v. 

Commonwealth of Pa. Dept. of Pub. Welfare, 502 A.2d 318 (Pa. Commw. 1985) (requiring 

coverage of wheelchair with 500-pound carrying capacity). 
38

reasonable standards requirement and implementing amount, duration and scope 

rule. 42 U.S.C. § 1396a(a)(17); 42 C.F.R. § 440.230(b-c). Relying upon this 

federal guidance, the Supreme Court vacated the Second Circuit’s decision 

upholding Connecticut Medicaid’s list of DME exclusions. Slekis v. Thomas, 525 

U.S. 1098 (1999).

20

 

Moreover, HHSC cannot claim to be in compliance with the DeSario 

Letter’s requirement that states establish “reasonable and meaningful” procedures 

for making individualized determinations of DME coverage, while arguing that 

Linda’s access to this process was not warranted. HHSC Brief, p. 26. According to 

1 TEX. ADMIN. CODE § 354.1039(a)(4)(D), medical equipment may be covered 

when it is medically substantiated that the requested item would “serve a specific 

medical purpose on an individual case basis.” (Emphasis added.) Molina failed to 

apply this standard to Linda’s wheelchair request.21 HHSC failed to do so, as well. 

HHSC cannot evade this fact by claiming that “Puglisi did not request exceptional 

circumstances review of her request for an integrated standing feature.” HHSC 

Brief. p. 25-26. It was incumbent upon Molina and HHSC to apply the correct 

medical necessity standards to Linda's prior authorization request.

 

20 The Supreme Court Order stated: [P]etition for certiorari granted. Judgment vacated, and case 

remanded to the United States Court of Appeals for the Second Circuit for further consideration in 

light of the interpretive guidance issued by the Health Care Financing Administration on 

September 4, 1998. (emphasis added).

21 When asked in discovery whether an exceptional circumstances review of Linda’s prior 

authorization request had been conducted, Molina objected to the question and provided no 

response. AR 327, Response to Interrogatories No. 10 and 11.
39

HHSC’s assertion that Linda relies upon a “vacated opinion and judgment”

to support her position that a wheelchair standing feature is covered by Medicaid is 

incorrect.22 HHSC Brief, p.28. As explained above, Linda relies on federal 

Medicaid policy and dozens of federal and state court decisions spanning more 

than 30 years, all of which make clear that states must cover items of medical 

equipment that meet their DME definitions. See n.19 supra. And as explained 

above, CMS recently reminded HHSC of this Medicaid test for DME coverage. 

Puglisi App. 1. There is no excuse for HHSC’s failure to apply this DME coverage 

test in Linda’s case. 

HHSC devotes a considerable amount of its brief defending its erroneous 

coverage determination by attempting to refute an argument Linda has never made. 

To be clear, Linda did not file a rule challenge pursuant to TEX. GOV’T CODE §

2001.038. CR 3-31. Nor did she ask the trial court to invalidate Medicaid rules, 1 

TEX. ADMIN. CODE §§ 1031, .1035, .1039, and .1040, or “to modify the Medicaid 

Home Health Services program.” HHSC Brief, p. 30-31. As explained in Section 

D. above, Linda has no complaint with these rules as each supports her entitlement 

 

22 HHSC acknowledges that the three “errors” identified by the Fifth Circuit in Koenning v. 

Suehs, 897 F. Supp.2d 528 (S.D. 2012), vacated and dismissed as moot, sub nom. Koenning v. 

Janek, 539 Fed. Appx. 353 (5th Cir. 2013) did not relate to the merits of the decision. HHSC 

Brief, p. 28. Moreover, the Fifth Circuit found the case was moot because, on remand, Medicaid 

had approved standing wheelchairs for two of the plaintiffs and afforded a fair hearing to the 

third plaintiff on the issue of medical necessity. As described by the district court, two of the 

plaintiffs had significant spinal cord injuries and severe functional limitations. 897 F. Supp. 2d 

at 545-536. These functional limitations are much like those experienced by Linda Puglisi, yet 

Texas Medicaid eventually authorized standing wheelchairs for all of the Koenning plaintiffs.
40

to Medicaid prior authorization of a custom power wheelchair with integrated 

standing feature. Rather, Linda asked the trial court to reverse HHSC’s hearing

decision because the agency failed to properly apply these rules, and the criteria

established therein, to her prior authorization request. HHSC’s protracted 

arguments concerning rule challenges under TEX. GOV’T CODE § 2001.038, 

including the redundant remedies doctrine and the constitutional separation of 

powers requirement, have no bearing on this case and require no response. 

HHSC’s Brief, pp. 30-41. 

While Linda does not challenge the legality of HHSC’s DME rules, she does 

maintain that TMHP’s policy excluding wheelchair standing features from 

Medicaid coverage conflicts with these rules, and as such, is an invalid basis for 

HHSC’s decision on this issue. Failing to apply the correct test for Medicaid 

coverage of the recommended standing feature, HHSC regarded TMHP’s policy 

exclusion of wheelchair standing features as binding on its decision and concluded 

that “mobile standers, power standing systems on a wheeled mobility device are 

not a benefit of Home Health Services.” HHSC App. 2, Conclusion of Law; App. 

3, Conclusion of Law 3. The agency ignored the fact that the recommended 

standing feature is a specialized wheelchair component and specialized 

components for custom wheelchairs are authorized for Medicaid coverage by 
41

statute and rule. TEX. HUM. RES. CODE § 32.0425; 1 TEX. ADMIN. CODE § 

354.1040. 

TMHP’s exclusion of wheelchair standing features meets all of the criteria 

of a “rule” identified in the Texas Administrative Procedures Act (APA), but was 

not promulgated in compliance with the Act. Pursuant to TEX. GOV’T CODE §

2001.003(6), a “rule” is defined as:

(A) a state agency statement of general applicability that:

(i) implements, interprets, or prescribes law or policy; or

(ii) describes the procedure or practice requirements of a 

state agency;

(B) includes the amendment or repeal of a prior rule; and

(C) does not include a statement regarding only the internal 

management or organization of a state agency and not affecting 

private rights or procedures.

TMHP’s policy clearly meets these criteria. First, this exclusion is a 

“statement of general applicability” interpreting law or policy and affecting all 

Medicaid beneficiaries in need of this custom wheelchair. See Texas Alcoholic 

Beverage Comm’n v. Amusement & Music Operators of Tex., Inc., 997 S.W.2d 

651, 658 (Tex. App.—Austin 1999, pet. dism’d w.o.j.) (finding statements in 

agency memoranda were rules because they imposed binding instructions affecting 

private rights of all similarly situated persons.) As HHSC’s decision demonstrates, 

this policy exclusion dictates a specific result - a finding of non-coverage of the 

standing feature - without regard to the required test for Medicaid DME coverage. 
42

Both HHSC’s hearing officer and reviewing attorney regarded this policy as 

binding on their decision concerning Medicaid coverage in this case.23 

Next, TMHP’s policy limits the scope of custom wheelchair coverage and

essentially amends Texas law defining both DME and custom wheelchairs. The 

plain language of TEX. HUM. RES. CODE § 32.0425 and 1 TEX. ADMIN. CODE § 

354.1040 makes clear that Medicaid coverage of custom power wheelchairs 

includes wheelchairs with “complex or specialized components” like the one 

recommended by Linda’s treating medical providers.

Finally, this policy is not a “statement regarding only the internal 

management or organization” of HHSC, but rather, is a bright-line rule the agency 

claims is dispositive on the question of Medicaid coverage of wheelchair standing 

features. See Combs v. Entertainment Publications, Inc., 292 S.W. 3d 712, 722 

(Tex. App.—Austin 2009, no pet.) (holding Comptroller’s policy statement invalid 

because it was not properly promulgated pursuant to the APA.)

Neither HHSC nor its contractors can limit the scope of the custom 

wheelchair benefit by establishing a policy that conflicts with the express language 

of state law and agency rules. Yet, TMHP’s exclusion of wheelchair standing 

components does just that. This policy fits squarely within the Texas APA’s 

 

23 Pursuant to 1 TEX. ADMIN. CODE § 357.703(b)(3), HHSC’s attorney was required to “review[ ] 

the hearing decision for errors of law and fact . . . .” Like the hearing officer, however, he failed 

to apply the test for DME coverage established in federal policy and to determine the legality of 

TMHP’s policy exclusion of wheelchair power standing features. 
43

definition of a rule, but was not promulgated pursuant to law.24 As such, it is an 

invalid basis for the agency’s decision that the requested wheelchair standing 

feature is not a covered benefit. See El Paso Hosp. Dist. v. Texas Health and 

Human Servs. Comm’n, 247 S.W. 3d 709, 714 (Tex. 2008) (holding HHSC’s 

policy establishing a cut-off date for Medicaid hospital claims that did not appear 

in the agency’s base-year rule was not properly promulgated under the APA.) 

This Court’s recent decision in Texas State Bd. of Pharmacy v. Witcher, 447 

S.W.3d 520, 535 (Tex. App. 2014), supports this conclusion. There, the plaintiff 

sought review of the Texas Board of Pharmacy’s final administrative decision 

suspending her license. Witcher argued that the Board’s reliance on a policy 

mandating this penalty was arbitrary and capricious and the result of improper adhoc rulemaking. Agreeing with Witcher, this Court upheld the district court’s 

decision finding that the Board’s “policy” was, in fact, an improperly promulgated 

“rule” under the APA, and an invalid basis for the imposed penalty.

The same is true here. There is no statute or regulation that supports 

HHSC’s decision concerning Medicaid coverage of the requested standing feature. 

To the contrary, the requested wheelchair component fits within the applicable 

 

24 The APA requires state agencies to provide notice and the opportunity for public comment so 

that affected persons can be heard on proposed rules. See TEX. GOV’T CODE §§ 2001.023–.030. 

“The Legislature delegates formal rulemaking power to an agency in the expectation that an 

agency will ordinarily adopt rules of general application through that power.” Rodriguez v. Serv. 

Lloyds Ins. Co., 997 S.W.2d 248, 255 (Tex. 1999).
44

definitions found in state law and regulation. Yet, HHSC treated TMHP’s policy 

exclusion as binding on its decision concerning Medicaid coverage. “Arbitrary 

and capricious agency action [ ] may be found when an agency improperly bases 

its decision on non-statutory criteria.” Public Utility Commission v. South Plains 

Electric Cooperative, Inc., 635 S.W.2d 954, 957 (Tex.App.—Austin 1982, writ 

ref'd n.r.e.).

In sum, HHSC failed to apply the longstanding test for Medicaid coverage of 

DME, and instead, relied upon an unlawful exclusion that violates the requirements 

of both the Texas APA and the reasonable standards requirement of the Medicaid 

Act. 42 U.S.C. § 1396a(a)(17). HHSC ignored the scope of the custom wheelchair 

benefit established by the Texas legislature and violated the Medicaid Act’s 

amount duration and scope rule. 42 C.F.R. § 440.230(b-c). The recommended 

wheelchair, with all of its custom components, meets HHSC’s DME definitions 

and fits within the custom wheelchair benefit established in state law. HHSC’s 

conclusion that the recommended standing feature is not covered through the 

Medicaid home health benefit is wrong. CR 348-349. Having found that HHSC’s 

decision failed “to comply with controlling applicable federal and state law,” the 

trial court correctly reversed the agency’s decision on the issue of Medicaid 

coverage.
45

F. HHSC Violated Linda Puglisi's Procedural Due Process Rights.

It is well established that individuals who apply for or receive public 

assistance such as Medicaid are entitled to certain due process protections, 

including legally sufficient notice and the opportunity for a fair hearing, when they 

are denied this assistance by the state. Goldberg v. Kelly, 397 U.S. 254, 90 

S.Ct.1011, 25 L.Ed.2d 287 (1970); U.S. CONST. amend. XIV; 42 U.S.C. § 

1396a(a)(3); 42 C.F.R. § 431.200 et seq. While the trial court did not address the 

due process violations asserted in this case, the hearing record demonstrates that 

HHSC failed to enforce Linda’s due process right to legally sufficient notice and 

further exacerbated this violation by sustaining the denial of Linda’s prior 

authorization on grounds not identified in Molina’s notice of adverse action. 

1. Medicaid Beneficiaries Have a Protected Property Interest in Their 

Medicaid Benefits.

HHSC’s assertion that Linda has no protected property interest in her 

Medicaid benefits is incorrect. As explained in Jonathan C. v. Hawkins, No. CIV 

A 9:05-CV-43, 2006 WL 3498494,*12 (E.D. Tex. Dec. 5, 2006):

Courts view welfare entitlement more like “property”, rather than a 

“gratuity”, and such benefits are a matter of statutory entitlement for 

persons qualified to receive them. Therefore, under the law, 

beneficiaries do, in fact, have a constitutionally protected property 

interest in Medicaid benefits. (Citations omitted)

See also Hamby v. Neel, 368 F.3d. 549, 559 (6th Cir. 2004); Thompson v. Roob, 

2006 WL 2990426, at *5-6 (S.D. Ind. Oct. 19, 2006); Ladd v. Thomas, 962 F. 
46

Supp 284, 289 (D. Conn. 1997); Ability Center of Toledo v. Lumpkin, 808 

F.Supp.2d.1003 (N.D. Ohio 2011); Fishman v. Daines, 743 F.Supp.2d. 127,146 

(E.D. N.Y 2010).

HHSC’s next assertion that Linda “has never acquired the benefits of this 

Medicaid program” is also incorrect. Unlike the Medicaid applicants in Johnson v. 

Guhl, 91 F.Supp. 2d 754 (D. N.J. 2000), Linda has received Medicaid benefits 

since shortly after her injury in 2011. Moreover, Medicaid beneficiaries denied 

DME requested through the state’s prior authorization procedures are entitled to 

due process. See Ladd v. Thomas, 962 F. Supp. 284 (D. Conn. 1997) (holding 

Hamby v. Neel, 368 F.3d 549, 559 (6th Cir. 2004), (holding plaintiffs had a 

property interest in the [Medicaid] coverage for which they hope to qualify.) 

HHSC’s own rule also establishes this right. 1 TEX. ADMIN. CODE § 

357.3(b)(1)(E). 

HHSC’s reliance on case law involving the denial of professional licenses, 

Neuwrith v. Louisiana State Bd. of Dentistry, 845 F. 2d 553 (5th Cir. 1988), 

termination from employment, Woody v. Dallas, 809 F. Supp. 466 (N.D. Tex. 

1992), or the distribution of insurance payments, Liberty Mut. Ins. Co. v. Texas 

Dep't of Ins., 187 S.W. 3d 808 (Tex. App. Austin 2006, pet denied) is misplaced 

and has no bearing on Linda’s due process rights as a Medicaid beneficiary.
47

2. Molina's Denial Notice does not Comport with Due Process and 

HHSC Failed to Address this Issue. 

HHSC and its contracted entities are required to afford due process to 

Medicaid beneficiaries when their “claim for medical assistance under the plan is 

denied or not acted upon with reasonable promptness.” 42. U.S.C. § 1396a(a)(3); 

42 C.F.R. § 431.200 et seq.; 42 C.F.R. § 438.404; 1 TEX. ADMIN. CODE § 

357.3(b)(1)(E). Included within these due process rights is the right to legally 

sufficient notice that contains, among other things, “the reasons for the intended 

action” and the “specific regulations that support...the action.” 42 C.F.R §§ 

431.210(b) and (c). The reason for this required content is clear. As explained by 

the court in Gray Panthers v. Schweiker, 652 F. 2d 146, 158 (D.C. Cir. 1980):

It is universally agreed that adequate notice lies at the heart of due 

process. Unless a person is adequately informed of the reasons for 

denial of a legal interest, a hearing serves no purpose and resembles 

more of a scene from Kafka than a constitutional process. Without 

notice of the specific reasons for denial, a claimant is reduced to 

guessing what evidence can or should be submitted in response and is 

driven to responding to every possible argument against denial at the 

risk of missing the critical one altogether.

Here, Molina’s denial notice failed to provide the required specificity 

concerning the reasons it determined the recommended wheelchair was not 

covered by Medicaid or was not medically necessary for Linda. This notice also 

failed to include citations to the statutes and rules that support the cursory 

explanation it did provide. In Thompson v. Roob, 2006 WL 2990426 (S.D. Ind. 
48

Oct. 19, 2006), the court held that the notices issued by the Indiana Medicaid 

program “violated Plaintiffs’ due process rights as a matter of law” because “[i]n 

the public benefit context, procedural due process requires “ascertainable 

eligibility standards” to be articulated and implemented, in order to guarantee 

objectivity and provide adequate notice.” Id. at *7. Molina’s notice included no 

ascertainable standards upon which its perfunctory denial was based and Linda’s 

repeated request for these standards went ignored. As such, Molina’s notice of 

adverse action violated Linda’s due process right to legally sufficient notice. 

HHSC seeks to excuse Molina’s due process violation by pointing out that 

the notice stated that Linda had the right to “obtain a copy of the guidelines used 

by MHT to decide the outcome.” HHSC Brief, p. 46. Notably, the agency 

overlooks the fact that Molina failed to provide the requested policies despite 

repeated requests by Linda’s counsel. AR 267, 268, 276. Like Molina, HHSC also 

failed to respond to Linda’s repeated requests to the hearing officer concerning 

Molina’s legally insufficient notice. AR 283, 284, 285. HHSC has established 

specific procedures for its hearing officers to follow when a Medicaid beneficiary 

questions the legal sufficiency of a Medicaid denial notice, but HHSC ignored 

these procedures in this case. Puglisi App. 8.

3. HHSC’s Administrative Review Does Not Comport with State Law 

and Further Compounded the Due Process Violations in this Case.
49

The final decision issued by HHSC’s reviewing attorney further 

compounded the due process violations in this case. HHSC does not dispute this 

point, but merely recites several provisions of state law and agency rules governing 

the administrative review process. These provisions are irrelevant here as there is 

no dispute that Linda filed a timely request for administrative review or that 

HHSC’s reviewing attorney issued a written decision representing the final 

decision of the agency. What is relevant is the action by HHSC’s attorney to go 

beyond the reasons for denial identified in Molina’s notice of adverse action to 

shore up support for the hearing officer’s decision in this case. HHSC App. 3, 

Finding of Fact 11. Due process requires timely and adequate notice of all reasons 

for the denial, with supporting legal citation, prior to the fair hearing. 42 C.F.R §

431.210(b-c). HHSC’s final decision violated this important protection for Linda 

Puglisi.

PRAYER

Appellee, Linda Puglisi, respectfully requests this Court to affirm the trial 

court’s decision in her favor. Appellee further requests all other relief to which she 

may be entitled.
50

Respectfully Submitted,

 /s/ Maureen O’Connell

MAUREEN O’CONNELL

Texas Bar No. 00795949

SOUTHERN DISABILITY LAW CENTER

1307 Payne Avenue

Austin, Texas 78757

(512) 458-4800 (Phone)

(512) 458-5850 (Fax)

moconnell458@gmail.com

Attorney for Appellee

CERTIFICATE OF COMPLIANCE

1. This brief complies with the type-volume limitation of Tex. R. App. 

P. 9.4(i)(2)(B) because it contains 12,058 words, excluding the parts of the brief 

exempted by Tex. R. App. P. 9.4(i)(1).

2. This brief complies with the typeface requirements of Tex. R. App. P. 

9.4(e) because it has been prepared in a proportionally spaced typeface using 

Microsoft Word in 14 point Times New Roman.

 /s/ Maureen O’Connell

MAUREEN O’CONNELL
51

CERTIFICATE OF SERVICE

I hereby certify that on this 14th day of July, 2015, a true and correct copy of 

the foregoing document was electronically filed, and that a true and correct copy of 

the foregoing document was served by electronic mail on the same date to:

Eugene Clayborn

Assistant Attorney General

Office of the Attorney General

P.O. Box 12548

Austin, Texas 78711

 /s/ Maureen O’Connell

MAUREEN O’CONNELL
No. 03-15-00226-CV

_________________________________

IN THE

THIRD COURT OF APPEALS

AUSTIN, TEXAS

_________________________________

TEXAS HEALTH AND HUMAN SERVICES COMMISSION,

Appellant,

v.

LINDA PUGLISI,

Appellee.

_________________________________

On Appeal From

The 53rd Judicial District Court of Travis County, Texas

Trial Court Case No. D-1-GN-14-000381

The Honorable Judge Gisela D. Trianna

_________________________________

APPELLEE’S APPENDIX

_________________________________

MAUREEN O’CONNELL

Texas Bar No. 00795949

SOUTHERN DISABILITY LAW CENTER

1307 Payne Avenue

Austin, Texas 78757

T: 512.458.5800

F: 512.458.5850

moconnell458@gmail.com

Attorney for Appellee
APPENDIX INDEX

CMS Letter to Texas Medicaid, May 21, 2013 ................................................. Tab 1

Letter of Medical Necessity, Dr. Lisa Wenzel................................................... Tab 2

TIRR Wheelchair Evaluation............................................................................. Tab 3

RESNA Position on the Application of Wheelchair Standing

Devices, Assistive Technology, 21:161-168, 2009 ............................................ Tab 4

Affidavit of Amy Morgan, PT, ATP.................................................................. Tab 5

Letter of Medical Necessity, Dr. Lisa Wenzel................................................... Tab 6

In the Matter of Mary A., New York Dept. of Social Services.......................... Tab 7

HHSC Fair and Fraud Hearings Handbook (Excerpt)....................................... Tab 8
TAB 1
DEPARTMENT OF HEALTH & HUMAN SERVICES 

Centers for Medicare & 1-fedicaid Services 

7500 Security Boulevard, MailStop S2-14-26 

Baltimore, Maryland 21244-1850 

Center for Medicaid and CHIP Services 

Disabled and Elderly Health Programs Group (DEHPG) 

May 21, 2013 

Kay Ghahremani 

State Medicaid Director 

Texas Health and Human Services Commission 

Brown-Heatly Building 

4900 N. Lamar Blvd. 

Austin, TX 78751-2316 

Dear Ms. Ghahremani: 

The Centers for Medicare & Medicaid Services (CMS) is writing to clarify our policy on the 

medical supplies, equipment and appliances (often referred to as Durable Medical Equipment, or 

DME) that will receive Federal reimbursement. 

DME is a component of the home health benefit, which is a mandatory service within the 

Medicaid program. As such, items ofDME meeting the state's definition of such coverage is to 

be provided to individuals (of any age) meeting the State's medical necessity criteria. In 

addition, CMS issued a letter to State Medicaid Directors on September 4, 1998 (see attached) 

interpreting state re&ponsibilities in providing medical equipment in response to the DeSario 

~ court decision. This guidance requires states to have a reasonable process for beneficiaries to 

request items ofDME not on a pre-approved list, and the ability for a beneficiary to request a fair 

hearing to appeal negative determinations. 

l 

We understand that the State of Texas is not approving requests for ceiling lifts provided to adult 

Medicaid beneficiaries, due to prior CMS guidance indicating that Federal reimbursement is not 

available. We are clarifying here, in a way that supersedes prior CMS guidance on this topic, 

that coverage of ceiling lifts under the medical equipment benefit is an issue that states must 

determine consistent with the process described in the September 4, 1998 guidance, and that 

federal reimbursement is available to the state to the extent that the item is determined to be 

covered. This means that medically necessary ceiling lifts will be reimbursed by CMS as part of 

the Texas home health benefit if these lifts meet the state's definition of DME. 

In addition, we would like to make sure you're aware of a Notice of Proposed Rulemaking 

issued July 12, 2011. That regulation proposed changes to the home health benefit to not only 

codify face-to-face encounters required at section 6407 of the Affordable Care Act, but to also 

propose definitions of a medical supply, equipment and appliance. Also included was a proposal 

that any item meeting any of those definitions. must be covered under the state plan, and may not 

be reserved for coverage under a 1915 (c) home and community based services waiver. We are 

working now to issue a final regulation. We encourage you to familiarize yourself with the 

provisions of that proposed rule. 

'127 I P-18 

000303 
~ 

J 

Page 2 - Ms. Kay Gha.hremani 

We hope this alleviates any confusion. Don't hesitate to contact me with any questions. 

Cc: Billy Bob Farrell, Dallas Regional Office 

Sincerely, 

Isl 

Melissa Harris 

Director 

Division of Benefits and Coverage 

·--------... ···------·----·-·----·-------·--------

P-18 

000304 
TAB 2
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·-·- Piuientl .. ·-· -····---.. · · --·-u11c1a Pugl~I 

.(la~ Qf· Bli(b: ~·!!liililllll ---· .. --- ···- --. ------

Dlfi3hosbt'. Nouroi1bron1etosls 'l'ypo.h1 Quadrlplogla·Ol·C~ lnoo111plete . Sub]eat: Jl~spo111e to Molln~J;l~e.lthQa:e's p~i!dlii1l:/10tl9•. fi!t9.l/4tom·wh'1"lohalr w.m; 

pqwer stannlbll andc seat olevatton l'ohture1. · 

Ta whom if mil)' ooncotn: 

Lind" Pust isl is twenty-siK years- old and has an urgent need for th~ ~ustorrr powe,·wh"l'lohair 

that wauec.enl!y.;eoorilmended :fur hO!!. Wldlo Molina Healtho-la requcsting·t~a! w<>·exclude 

th• "sei!t.elevc.tor" and "•tan.dins featuto and alf acoompanylnQ con;pononts" for Ms. Puglisi; wo 

do not •jlte• with iliese changes, ,i.s expfailJ"d b•low, 11 Is our pr.~feM.lonal epfolon: 1b3t tho . 

reoonmianded Wheolqhalr wtrh lnlegretod·st1μ1dlti3 f?IUre-.l1 m~loally n=sary fot thfa patlent 

Oil it wm tlllow h¢r to Independently. stand multl~l•·llmet eat1h day·whllo at home or fn.ttte 

oonihlunfty, Tll!s uooess Jo fleqμen{ atand.IJli;'fa na'l11'splity to-e9trec\ lit. M<allora.fa.the·pnmerous· 

med lee.! oand!tlons th•t Lindo faoes·duo lb·ptolongo~ slt!lll'g~l2 hoursY frl·a whao!chalr ov~ry 

day, Pleaa<I •ansldoo tho•falfowlnirlnfo<lJ!•lliia'°anoomlri".lhls eatlent'a medk.al eondltlon'Slld 

ouh'.ent medloal nood•1 

Dla!jnosl!l-ijttd Funotlanat Status 

In N'oyombor. io11, Llnd~·aus«ilne4·a Cl-4 spinal cord Injury (lnoornplete} fultowfng a.surgical 

·procedl!reto r~inovo a tumor ne<ir hsr ap1no: As a r .. ult, Linda ha4 qu'!ddplegla, wltli very 

llmftad movement on her r)ght side. Lind.a does rotoln sorne movomont on hor left sid~. out with 

.llttllleH ral)Jl~•pt: motion., Linda also has fnoro011ad tono on hOrrlght side, whiOh.ftuctuatea ·Md 

causes spasrl'ts. Whlle Linda rotains good hoad CQntrol, her trl!nk aontrol and:~ontrol ofujipe~·aud 

lowor.oxtrernltiee·l$ poor. She·hu·boen·dlagnosod with i>sfcoponlo and ls Ill rlsk {or oontinJ.lod 

Jo" ot'\>onO'dens(ty. Llrida ls ah!o at inoroad6d ri•k tbr pressure so~•• due to oompromisod.s~ft 

tlswe'lntegrl1¥, Linda also ~xportemm Imp•~ mplratory tunolfon, nourogonto bowel, 

neuralogl~iil paln,.md Impaired lntp,11.umenlar;' a¢nslillon. Reconlly, Lind!!. w~• ajso di•~nosed 

with NaU!oilbl'o'n\atosls '.l'ype 11 (NF2). 

Due \o 1!>~ n~tura \!lid severity of Illnda" 1~iuitl .oorlifr!J~ry, sM.Js.,depoJt.de.rir.on :a !!OWer. 

l'ltleclohaf\"for fn®pendeni mobllll)'• Tn·additfott; Lhtda0 requlm caregiver mlstanco kl itansfer !~ and"Qut cif her bod.1μ1d ytheelohaii;. She ~!so utl!fzen L~fl Mobile Ann Support ti>.lnorelj!lo 

fiet l'unctfiinala&llltles and to partlolpat<> In actlvlt!ef of·dally. llvlna, With ild"<tu•t .. suppot\, 

inoludlng u~cen·to Independent standing, .Linda can porfor111 somo.aotivitloa·of <!ally Uvlng as 

well .. manago·her pain. . 

Wheelchair Asso1Sment and Prior Au!horlzatlon Reguesf 

A'oohlprohlmslvow'heelobalrass•!amont wds-oondu'oted in Fobruaiy 201·3 whlJo Llhda·wa& 

reoolvlng in'patlo'nt 'rehabilitation ••rvices·at tho Te•u Institute for Research end Reha&U!tadon 

(TIRR). Wo r<:eommendod • powo.r wh~olcbalr with custom foaturoa, lnolui!lng a scat elovator, 

integrated standot, and oevorai other cU$tom comp.onenta. In thfa evaluatfon, we'ptavlded 

lnforma(f on con~ernlng L!nd•~ s medlcdl neod l'Or es oh of tho rooomme~dll<I. duatom .ctlm~ononts, 

A requc~\ f¢r, poor autjloriZ!lt!Qn of tha qlJl!tom power. wh..,loh.alr .recq!IUJ!el1o~d by Linda• s OT, 

----.. -.. -........ ------·--·-. -- -·--· -----· .l_L ... ·-· _ ... _ --------·-----·---------- --

000050 
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. · .. . A.ii,-~;1d'PMJlpJ~~~·i~.~ w~s·sub"uifr!ed to Malina L:fel(lthq11ro·~l!M2013;Jo;1t}prll.1.2; - ·· ·--·---· · 2Q·j~, Mollt\11 .Honlthcai·o roqueste4 thut w.o:.1nake nvrnerou• ohango• to·U11dn.'s p1jlor . 

000051 

~utliorfaa(io•i 1·eqM8);;the l\10-".t n0t01f;10 ot' wlu~h wM th~ l'emovnl llf\ha ctistoin 1i\ie1f1'!1t¢ 

Mnndi11g.fe11tffi'• and ~opt ~l•~Mio,n:cqmjl.ot1•11t. •n sh'oultl be n<.>!JldSl1'1t the apo~lflb wl1\lGl~halr 

roeoll)tn~nc1~d tbr.Lfod1t- tllo•l?equo'btl CJ~O,(} VS.-:roquh'i;s a Qroup-.4 busii-. .. WJfl1.scnB~fovntien 

and·int~grated standi11g. fontu~ \0 ·p~Wmlt lhe.vaer to;indop&1de11tly .a rand. AHuoh,.tl\ese 

cotnP,on-antB'. Qannot be "'<rciilO.Ye<l" ifom.the prlor·au1h~til,atlon i·~quesl withoul subsltir1clall;1< 

.oh!lllglirg tl1e natute of'tM w.haelphah· rocommoaded for Li11d~. El~oau~e I\ 1·~ our JlrQlesijlona( 

t!pinlon that !hose ·oon1)lbn~nil1,.11J'e medl~ally .n<lC<lS'>lel'Y fat' Lindu, we write lo ~rovld'e:.fudher 

jusHffoijtJon for·the re<(U0,9ted wheeJohnlr: 

Medlon! JuMjf!~afjQn for llcco11im·C1lcl•d Custom Power WhqelQbbll' 

A-s pr.evla~sly ttcttatl. slnndlng is critib!ll for 'undo to p>'OVent 11.trthar lass of bqn·e density imd rfol1 

of bon• l\·actures: d.em-oaso.musol« tone 1u1d spn•Hoilyi nia!nialn splMI 1tllgnme11t .und 

delay/avoict HRele1al defonn!Ues; exlend hor uppor lrunk ·10 roouo.o p1·ess1ml oi1 lntomnl ol'gans; 

maintoi111·a11ge ofinot!urt: h1cteasd-ff.o~lblllty.itnd pt«>v.~rit.~~tt~·uotut'll~ ~-~th~ lll)l1

, knee, and 

unlcle')oll\mi prev.Qntpr~ssur,j. sotear Jmp1·ove"tltlim1'~· h'ilot d1·11111nge ~nd renal :l.'lu:iotlon: acldross i;us!rolt1tesmr11~ 1-asp.fi:nttiry, '!\l\tf~pwel:J\Jn~tlo(l) •nd innf!lt~ltt 91.irdt~vaao(1l~r h~Jtlr, ;fulitmna 

ArvR1 ~t nl., R/16WA. Po:1.l(lrm, 1m tM tf.pplt~(Jlfpn ofJT1hqd/oft<1fr:"/f1amltng J;)ovlco~, ·21 AsHisUve 

·reohrioloi;y, 1111-168 ~2009) 

Accoriling to llBSNA, ib<;-reccmmendcd f!•cq11e11ey·6f standing foraohl!:\!fn!J thes~ m'edlca! 

bon¢fris la""a$ ~t\:cn.ua the t1~er·on11.!"0ler(lle aoo.l'!hftably; ... ," U.rilikO'a aepurote,atnndei· li1nr 

woul<I J'eq11h-e-Lhiilii· to havG cal'oglver. μsslshmee·~Aoh thile llho .uses tho devloe, ttie 

r·eco1mMnded wheeJehoir will alluw Linda to iadopendently,stand'~s otten as.poa~ible-Md'fo ~11y 

1ocnt101" wlfether at home 01• In the oommu11i~y. RC..eal'oh demoustrntes that sl101·!, frequent 

sl11110Ji1g.is.mol'o ell'llcth>eill llllprovJng boncden!if)' 11\ni1 one lonfrstandfng episode, ·wltl1 th~ . l"oconlmended wheel.obair, Linda wifl be able to. ~tnnd moi·eoften and for ~l1ortor p6riod$,'making 

enoti $llliltllttg op1Jortun!ty mere effective hi preventing bon1> loss and Pl'Qll\oliug ~une clenslt~. 

Acldillonally, th~ reoommended wheelolmlr Y?lll pl'ovfole Lindi! with xopanto\{ oppo1·tu11f(les tor 

"dynamic Jondlng" of the bones lt\.hcr lowot o•tromJlie.9, For example, dymunio lonrllng occiu·s 

tlul'lng tho fUahsllfon fibll! Sitting to atoniUhg_. lflln htdiv.ti:lual staods fn a sepo1•ale;s'tander fon one · 

ham·, dynmnro· 1ondi11g ooout~.onl,yonoo. f!etn h1dlvid\ld( gMU :froin s!LClng· 1.6" sturoclJ11g111.\lnof,(lua 

llmes·evory·doy, more dy.1ia01!0.Jcntllng 000U1:s1 with grertt bo11etlno the user'ir.qvernlJ bone 

henlth. · · · · ··--~-·-···-- · 

Jt ill imponnnt to e11lpl\asfa:e that.Llild.n pm'l16ipat~d llL n fl'lal of the Pel'll1obll t10wer star1der wlih sucees~iu stondihg 011d d'rivil11> tire' chair. WiU1 rtw·recommouded wheelchair; LitJda·w.HI be 11ble 

lu lm;!op~ndon!IY attmq 1>mltlJ1l~ limes enoh dny, withoutdsk Qf t1:nn•fer inj1try; Md 1·ouardlosa of 

her loonti6fi at h61he oi: in \fiecc11m1t'1llt}'. This Increased frequency of stoodi~g .will nrnxlmfze 

the r11ediC11I (l¢~clflls 6"f stancllng, including l1utno1 limlt~ct to, providihg com'(llete firossui-o 1<1t1er 

from prolonged si tl!ng; 111nh1t<l41)11g bone density, deol'easing musol~· to11e, impi"Oving oil'eulation, 

hioren~.ing ro$J?h11roi:y· fonction; and inaintnining/hnpro\<lng ra11ge of motion. to hip~, kt1ues and 

nnltlos. Reduel111} or ellmlnaling lho ocuurronco of lhei;• lll~tllcal compllcaljon• tl'lltn prolpng~d 

2 

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·sitting .y;J{l hofp. Linda malt)tain her health and woll·belnl,! and dearoMe th'.• aseoolated·~d•t•· of. 

her'future medical care. ........... ·-·· .. -·· ·········-·'"···· 

Again, it:ls OUJ' professlonSt oplnlo.n that the recommended·whcelohalt.Js me<;llcally. ne~essap1 'for 

L.itida and will ameliorate ·tho numerous .medlc!il compHcatlons she ftices d4e to tho s~verity Of 

har dls~!illlty. It Is also our opini6n thatthera ls no other it<:m of equipment ot comblnatlon of Ot\ul~ment· that can a<ldress lier complex medic~! needs. We ~sk that you .¢~!\Jlly review ·th~ lnformatlon provided on Linda's b~alfand approva"the recommended·wheaJchalr for har. 

·Sinderaly, 

WV-' . . ' 

Lisa Wenzel, M.D •. 

@006/068 

3 

33- ---·------·--------------------------------·-

000052 
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... ·-·-· ·~ ---· ..... 

WMalohaMS c.oo.te·r/Str-lilllel' Seating· Assessmen f.'Porm·--· ·· 

------(t;cpjl{ome He11lth S.eri/lcei>).(7' page13.) 1.. .. 

········ ··--:-· 

t~!ftot'·oita:~~\{·?i!f.;~!~~~~~'(~ili~: ~, ~~- ;~ ··~!. ~11-?f~-J~t>?l~:.s ·.:~~ ·-~r w:f·'i1·1 ·~·,,, .. ~!-"''¥ : ..~:,~1--~:n1:\,:·~· ·.~.; • ····'!ti!; t ....... q .~" ·-!:J'.( ·'·t-·~~;~~J.;~;. • '·' _,. , ' .• !!' . i\ • . , llo'f •.• 

A outrvnt.-wh~ell!halrl'-CO<>.tor/•!roll~r se~Ung •••~••m•nt,i:<>OPUd\•d by- b p~yalelen or • phys[C.f dr aoou~aUonal tti~raplet iml•t·t>e com~iet•d for puroh••• of or meJor modllldall¢n• (ln,luolng MW sbatlh~ 

systeli'l&) lb a wheeled moblllty ~al~m. A.Quallfled·Reh.abllltatlorr Proiesslonal (QRP) mvstbo ptessnt 

end partlelpate In Ille seating ••••,.m•~l (ar •II Whe~l•d moblllly .sysl•fl\S and major mad1H~tf9no. 

P,le~Qd :attaoh:rnanur•oluf!lr·lororpi~l!Qn, do~orlptl•nJ.<0nd an itarnlOl!<J bt ol rotll,11 Prlo•• .of ..u ~qij/tlon• tMt·;fe noj:lnqlooed.lh:lla~.• model Prl••· . 

comp1•1• .Sae,aan; 1:1Jlf for·marl),jl!i Vlheele~ m90Jllcy ays!~qJa •. Oempl~ta ll•otlqns t·l~i'fot.P<lW•r 

.heeled 111oqllll otomo. Cpmpl•t• thA Home ti althtCCP •••uM . •O<~o••lfor,all rtlqu<>slti. 

tle~fi~•.:ll•nf~ mual>I~ JqM! Llnqa ·hl!)l lne~••!!Jld tog~ln RUl:,enq LJ!':,wh1ch flU.014•Jea a~d o~ ... •pooma at.tl!]t,..,. ·$Ji~•llo~ Is pre¢11l'livl>Ull~<1UI !ha·i(Uf: "1111-~L6'"1 a~ter1orehd1'••l"W mUSCllla!qre-ol the olbow, wtl>t, fingers and.litp; .. ,)'lolf &HhbU!derlnJernal ro~ kl\~~·•xten~~rs1 •rr! pl•ntar ri•xo11; M tnor,e, .. lb i)iuaele•llfn~ i..pi:01•n\ ID· L 111R add40)or11> knee.f!al<Qfe, an,d anJ<le 

plarMr fl9xa11. t:t•cr•~•94 IT\Uaol• toM l«nsted in Pfll~lmal We·musoijfolur.e. · 

DescrlDe: ~Ql!Ve 1Aiovemaiifa a e d ,by muscle·toi:na: Linda demonsltB~s lllUe·aofJVe tnovemerit ln·the: 

RU a and RlS. Sf'ta:·1s eble1 however to r.i.se-fh11 L i)ij's other bocly iacll\!ely, ~!though ran a a of motion 1~ 

llm'~ed throU1fhOut. She.lubl•~o puoh through both legs durtng transfer<, and can parUaJly flex har L 

kr.tr1e, l_n the tJCs, Uf.lda has no·eottv&roOVF11ment thloughoul lhQ RUe or L atiouldat and llJ not·able-to 

•_uPJn_ •_te-; She _db&S_ have adUvo:movemsr\t within horrnal llrrirts dt&tauy, ln·el!:>ow ext$ntiorv, and for wHst 

& :tlnger ffaxldn/e~lanslori, · · 

Detcrlbe-passfYa·mGvamenta.e'ffeoteO.by. mueClGlone; Passlv.a ·rnFJ\tements-aff!!!C:ted b.~ muacJe tQnQ 

lncfude.bllatefBI shoulder. fle>rlan and extension, shou!de'r_ abdUCtlon1 external rotallel'\; and bllal&ra{ hip' 

abducHon and enlUa-doraiffaxlan. 

44 

llJOH/CU 

.. - ----------~-~---------~·-------- ·--···-···---- ·--~··--·-----·--------------------------····-·---------~-------·--

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--·---·-. - -···-- - ·-· ·-·----- --·· -- ---·-- -... 

. .. __ ___ Daeollbe. reflexes prase~E._]"hrOyQh_q~_e!J !!'.!~.PY ~~!_~J1S, Linda has not demonatratad any proteclJl/e ----1

or poetureJ fefleX.ee, ---:-·----- --- ·------- · --

' ;rrvJJk 9.QPl(ol: 0Good 0 F.alr· 0 Npn~: 

\.JpP,at exlhltnltles: Q<pooq OFalr 18! ~eqt Oi'lona 

L~~Ef!'!'J~~~; OGoo~ 0.Folr l)lJ P,oor f'.J.Nena 

Qesbrl~t1-~rth9pfldlo·coodtllQD' .•n~t.ot rli,ng~.of in'otfQ)l llf)iltat\one req4l~rig'1P.Ml•I pon~lq~r~1lon (t,e., cc11\r~ot~re~,·~i!j1Ta,e·(!f @lnal co!V);tut,., e\o'.): GIVen 1~9~:of lh!ll}c ~i;mfro/i QO{j8.1<!_s~ffl>n:mqsF/Je 

m~.d~ f9r.tt.b•.ak f!l•~:Pl'QV(dea,1S_~blo•l(nff:~"l!$.lf(~ntn~u((.~fiq{(gn,m~flt ae t~~"!l>l~o ~ pl'W~nt rotld\a11•aP culY'!furrF ~~~ani!~IY,'·lll l(f!Sf~(Qn/ng. 'J,ind,R11t'Nfgnlfll)anl/y.i!~cro~sed htp ,!lliiM J<uqutt:ai; sho lravo:a ous/i/on•tMI provillqs· fe1lhb1o· Js'¢hl•/·fioslllcri/n9 lo prevonOmbafanMd 

wefriflfwarlng; Gi1Yef1.iind11's spi'nel·~ol'dy.fn}f!IJ!r,she /q1sHncre11s~d rfsk-~o( b~ne </on•lt)('fos~ . 

anl:f oom rom/s.•d'So(f t/$SUe./n(og(/tyaoondsry·fo not'bsl11g able·to f>o•r wotg/Jt·tl!rou h Bt:&, 

tl sorlb~ ·otherphyafo~I 11mllatlons or ooocartt• (le., 1aapltotocy}: 'P.stl~n.t has ·!nipalred'integumsnlliry 

sensatlqn1 respJra[ocrfUnoUon1 neur.ogenlo bowel, ~t\d l'\Sbrclogloel,paln. . 

Oa~orfba any recant· or axpeolod changes In medlcaVph\'•ical/tupcllonal sia\us: Than~ ate no ra0eni or 

0xpaoled changes Jn mBdloa1 etabJs. Pallenf has regained some muscle fun·cuan slnae the onset or her 

fnJury; the1efo1e her funottonal •tatu• may otranga·over.ume, · 

If sur9sfy. f;.en)lolpaled, plea.as Indicate lhe·prodedure and·&xpeetad dater .NO·SU(\i10ry_la·anUci~ ad at 

!hie tln>e. · 

45 

1"JQ15/QU 

~ --~ ---~-- ------------------·-------~----~-----·--·---:--------·---- -·--·--··-·· -· 

000064 
) ' ' 

Page 16 of 68 received on 5120/20131:33:06 PM !?acme Oa~lghl Time) 

®·NOnambu(alory-. -· __ --· _Q_WJ)h.a~slatonq<l. 

_ lndtdat<l'lhe cl/enl;• ambulaUQn 

polan~a/: 

0:9'Iiqr_t.dlst~noo( only 0 Porr.m)pnily a.rTJbO/atoi:y 

O Expeated,wlthln 1 Yasr 

tlll N6.l •~t>Oot•B 

0 e~¢e~t~d In Mure WJlhl~ years 

.1 .1 l =~-~~1~~~',,,.""'l'JU.""'"""""""""'""""""""'""""'-""""""""""""''""".c;:.;_~~"""~ Wheel<>bair Ambulatton! 

I• eUent t<\talJY·de~El)JJlenl upon whaelc~alr? t8I Y•s O No 

If no, pie.as& e)<p/aln: 

lncl/.,.ta the ollan~a transfer P~PablffQ.eoi· 

Is Iha cll•o•tuba feM 0 Yes 

lfyas,_pl•al!O axp/atm 

l2il Maximum eas/etanoa 

o·Ni1rilmiim •~•1stifr1oe 

i8l No 

Feeding: • t8l Maximum aa&!slaMe ·8 M~derete asaletanO,e 0 Minimum assl•lant;e . Jhdepanaonr 

O!l•orJbe·olt\er e.cHvlfl~~ j>.erfolJ)'led'Wh fo ln wheelohaJr.,Groomfng ahi:f hr,!jlen& a.otlvi~\!.~. ll~ ~re4~1~d. ~erba/ a.nd.techno11191cal O'omh1urtl0'1tlon, voldlhg, andihetapeuttc aetlvtt •• lncludl~g ROM, strengt~enlng, an~ weJg~tboarlng ac!Mtles are.all completed by Linde in the wheelo~alr. 

ls-lhe homo' aoc;essitif~-le (he Wheelchalr'I !8l Yes 0 No 

fire ramP• ovE!lli!blo Jn lho home sett!ngJ1· Uill:Y•• 0 No 

CleSGrlbe (ha cllont's·edUcatidt1aVVooef/onal satt/n~: L/n~a I~ unemployed ~acoMaty to her olsabillty. 

I• Iha schO"o/ aoceaolbla lo the·wheeloholr? O Yea !81 No 

-~ .. c--------·----------------·---~--4.6 _________________ , __ _ 

000065 

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- . 

,Ar~.tb•lo. ramp~·~v~n~~I• In.Itta Mtto.ol •~ltl.na2 GJ Y.es ~ N9 

lf·cli•nt·l• l~:~clibal;'has a acMol ln~raplsrbaanJnyoNad·ln thd,as••••inen\? .D Yes 181 No· - .. ·~ 

N•ma ofacnoQf.theranlsU NIA 

N•m~ of $choo[: NIA 

b;St:iib."Wh_er_e_'~lh~e-w~h-ee~lb~h-•1r-w~ll~l.b-a-afu-re~d (~h-om-e-.-.n-d~~-r-s~oh-oo...,_.l)r~h-o-m-e---·----·-, 

1--,---.,.------...,---,.--:-~;;-.,...,,-__,, _ _,~=-------· .. -·• .. ,,_, __ _ D•••!ibe·w~y current soatlng system ls.not mooUng ·oll•nV'~ needs: -NIA 

Descrlbe lhe medical nacasslly for moblltty. bas~ and seeURg, system-req~astad:• . ---- Determined vta,extenolve tnals1 the sealing aystom ollnlcelly rneommendad fbr Lfn~a .lnaludos: 

Pef!1iO.blle C6QQ VS· Stend01r pbwor mobility base, requ~•d to enable f\lnctlons of.the Whe•lohair ••a 

whole arid lhu$:·anow ~Inda to mano~~•r Within her homo Independently In a as(!; end reliable manner. 

i'i"t.$ealWldlh, ~:!~.~~•l depth •.bt~rdlng lo ciln!di>l maa~urartiehl•Uated below .. 

~-n•t remoia.joyatiok, color djsplay with mono·Jao~s (mounted on the left, as Lind'~ has ae!lv~ "•e·af 

these fingers.using.her DIP joints) lo allow Linda to qpereta·lhe wheelohalr-ln ell dltootlons·~nd a~gage 

the power1 Ult1 reol!ne, and stantlln~ fe:ittvres. 

R"1el rettaotabla )oyetlck mount aUMJiea·U1e)oysfti:!(IO ttta vlheeloh~it.foi o~erallon. . . ~partl!El~Jir.contrOI '!11th h~me.$S t<r raq\l Ired I<! ~p~r~tlil mere "11!eJ'I one power eeat· l\ll'!~lfon. Th~· 

• pendabld.Q9ntlo/ wi!h.liarne<is All.om the "9.nttol.unfrto.mova til llja:.sttl~ _¥.. at If do~~ nelHl~<fania ~" 

·• 

~, ... -. ~ . ..,.~, ---·-·----------------,,,,,,,.,,,~Ji'ilo"'· ·"'Diii=01"'91"'"· '"'11"'1R•"'•'"'•"""'"'i,,,,_ .. ,,,. 1?n11 ... 

llJ~l7/Q56 

. ·-···--·····-·--·--__: __ · ·-.~--------·----------......:..1..7 _____ :._ __ __: ____ _ ·------------·-·---

000066 
·~· 

.~ 

Page !8 or 68 received on 5110/20131:33:05 PM ~aclflc oa~lght Time! 

o·a~·~ar tov.s~ df:!sks, 'and of her work .surfaces durfn9 funcffonartaeks. 

Power lilt ond·reollpe (eaturee snabl~ tar to.p~rr~rm !l•f·OWO' praoa4r~ relief wl1h. p;~~~r lr~qu9ncy-:-.,;a-­ ~"r~ilon to p/ei/"'1t prolong~dwelg~t beall/'lll ititqugh l•i:hlals.a)'td pre.vent •.kin btaak~awh. 

Multl-Sea1.control FunotloA.'Klhwlth Toggle Swltohea: .. raqulrad wm1 mars Uisn.ona.powar eaaf fUnotlon. 

Llhda·i• aU!e to use 11er bll>o lo opereto the fqgg)e swllehee !Or pdweffuncttone. 

611~/hg oackresJ kit .. with lil/~ln9 ba'OJ<reat·harelW~rel i'aqμlract to' reduce frldfloolahe.Elr whert ualnQ poV1$I ~tilrtdlng fe.!llur• end power radline. Sl!dlhg'baekreat hartlwahl Is rs~Ulted la mo~lit aftal'rrtarkst 

ba~kre$t 

Corpue·l\rmrests • 4"~16" \'iftfl.bliateral·elb9w blocks end rlghtoatsr arrnre«t·stjpp'cm. Tira allioW block• 

keept1qth ~lboW• from ta!Ong off Qr.catchlng'Qn the. armre•l~pt>StarlQrly. T~a'l'fl(M pUt(lr. •r<nre~t k••P,• 

her FR.elbow frbm falling off Md sllqklng ofl !he side of Iha armres~ preva~ttng risk cf Injury. Thia oooura 

freqμent!y wttho.~l an ootar arrriraat In plaoa. 

Power Elevating, Artlqufaling, Gant~r-maunH09t platlorm·(1.pfeqe): required tor lrana(ars<ln and out of 

tha wheelchair, w•lghlboarlng, neutral postural ~llg.nmant and.sere moblllfy within Iha horlla. 

Knee blocks: required rot use·wllh standing feature for safely. 

Standard, oon·p.aO:dad, medlumj pvsh-bvtlon hi!' po~IUorong b~l~.to ~1a//1taln l11ps In Wliaalohal~~aat sa 

wsu ·~pr.event faillng/slWtng.ou sfwhe~lobal~ 

6" x 6" hip gulqp~.V"lth rl\l1Jo'1P.PI• h~rdwar~: n!i06~a~ry to-ko•? hlP•·•Pd Jower·e>c.tre'm!Ues ln·&O,!Jtrel 

allgoment In 111mn~ and sta"rldlnl)', . 

AdNstabfo che~t bar (10' wide): oaoe'ssary for u•o wllh s!andlng fl)atwo lo vre~ont Ratient from fiilllng 

forward. 

BodypofntMonoflex CMsl Strap (medium):' recommended sa a safety Faatura during standing, and 

d\Jrt~g transpor,tallon when riding In tM Whoelchelr. 

i;ta~lth oomrort:Plus helli;Jrast (10' Wido) with ramo.vable hardware to maintain oer1loal.aflgnment end 

pi'evant-.lrtJUry In t!lr during pressure rellera. 

Pswer •eat elevator: required when vslng standing. featu,,., Power seat ala.valor will a lad dect~~se 

oaraglvor "uroen when assisting the patient with late rid l1a~slera fly adj usu nu tHa' •••I h~illlil ta mak~ tho 

transfor.cio.'!mhll!. TJ\a aeat.aleva!Qr·aflows for Linda to .accoea Items In upper oablhals ~nd. ,9auntertop$ .·. lhafshe would otherwise ba·.unable to reaoh. l='atlent-ma:y also use e:eat elavator·lo lmptavs 

lndependenoa with ·and fUnot/opal reach aotlvltles es her neuro1ogloal funotJon continues to Improve. 

Sl~ndln!l fB!ltute: THi>.atand1ng·teature.allOW• tlmfa to ~aarwelghi through s~i::a.as b.eca'asa1¥·t<i · Rt•V•iJt.borte deMlty 1~ .. and ~(0setva.lntasrlly. of'aQf.t Ua'sue slruol~~~ such as llgar/lfihtnno lendoru.. 

Tha •JJ>ndlng feetvr•'~l~o'!llOWs hel MPl3••·16'.lt<irns MC•$Sery lor •WiTyday (!)AOL actlvlUM. Linea' t~ 

able to perrorrn toileting with set·Up ohlY from s,upported.stan<(lng Wllh·tha use of a·f)ltnafe u.rloal. 

16" Wide, 16" tall Matrtx ~lite deep beokreat provides stable postur~! eupporl I~ prevent rpfatlbo.ot the 

trunK •nd ourvature·of th.• eptne. The height ofjhe backrsst'gJv~a naa~supp9rt throughovt the·fenglh 

·-·--···---·----·--· __ · ________ ·_·· ~------·---· _4_8~~--~---

000067 

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.. I 

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-------1ntt.inil_a'a thorill<, an~:tM.d•pth of.U)I~ model Rt•~•Dts c<Jll•p;lnff i:if~llheHlae,;rl\eri-lbb~g~. enWanolM i'asl)lt•llil~ and.p10ael)lln~.the c<lrteot allgn(llent 01 her •~i~Q. Tliaee'!•loments·_togalh_er)'J1al~ti•Jn /,Ind.&!•. lr\lh~:h'( a •~re, neUl(at pQeMe so lhet s_na v;ul not (equl!il'fr~q4en,l r~P,6aJlldn1ng, lt'IJ iTIP9r!iinl ner· 

sest1J1g.w•tel1J"Pr0Qlda.fo\!harjl9e\urat,. poaltionln~, ~nd rnoblil\9 ne.•o• •• ·~~ hab nQ 11n.•·tlylnQ 1n U\~ 

home .lo.rely"" to provid~·lhle c~re. 

----··-----------

1S'"X 2f)" Invacare Slab]lle, cushion.provide~ adequ~t~ femoral ~upport to pr$v<111l abdu0Uon oMhe lhl9hs' 

In altH11g .as wsll a~ lscjilaf P.•~lt/Qnlng In, IM (<lar of \be ~~·~ which pr'1venle.Llnda's pelvle·frem·UIUng 

po•larlor\y (w~l('h·woul~ lnqrea~.•·prassure-!hrougnoUl, !I)~ "'•O(•I region, •nd· lncrasu· mslall~J1•d ~U~1:t" of ~e-$plne);'T)le,gB\ overla;<·ln lhls r~gfpn,of.ih~ seql.Rrovld~s-eddad skllr proted\lon and 

DascMba fhe sqvi~roant ra~uesl.~cil Delarmloaij"vJ~ •*leiiiiive f(lals, ·lhe·a.-all~.9 •yale1J1.oliri1caQ~- -- r'IOommeocl~d lor. lln<Ja, IMludoo!_ • 

P•rn1oblle OGQO. VS S1M!'l,~r poworrnobllll)!·l1••• l\'no.1 rornot&JOY.•~ek, color dl•P!•Y with mono Jecke·(rnountad .on tha leflj R'MI relrac\ab1a )oystlck mount Expanda~le control With harrioaa 

Power Ult and·reoltno 

Multi-Seat· Oontrill funollon Klr with Toggle switch•• 

Sliding Dackreot.klt-wlth sliding bookl'!o•l her~ware 

17' aea1 wldtil, 22' •••t•depth Oorpus.l\rrnrosts ·•'•·16'"with bllateral.o1bow blocks an~ rlght ootar ermrijst sup)Jbrt: l"ower-ole.\lilflng1 Al'\lo!llaflng, Center-mount foot plalfOrm \1-ploce) 

Knee blool<S? requlced for use wJth· atMdlng leatu1a 

Stander<S, non-padded, madltJm, RU•h-b!Jtton hip p'o•lllonlng bait 

5"x5'' hljl ,g~lda•'Wlth removable.hardware· 

Adjustable qhsst-blll (t6" Wide) · . . · 

BP!IY.P,Olnt·~onoflpx dtte~t -Str!\p (n'le~l4rt1): 

.st~aith ~tnfort ?lus-h&adre$t·(10' Wl~el with tam~\1\>ble hardw•t• P.OW~t·.aat eleV~W . 1'S"Wl4~. 16' tall Maitl~ .el1t.e1d!f~~ ·~~pk(e'at 

17" x .ze" lnvscar~ ·stablttta Oll•~fon 

Qesoribo·Jha groWlji pbtontlal or ~qUlil\tla~traqu~at~d In hUtTiber pf yeero: LJ~da has'l(Jet ~P.PfOXlmall>ly q '. 

p<lunqo slni;llt Iba deuiof'lojury. Herwe19ht la 1nalrilaJa~~ vie nutrlllon~l lnJaiw··~pd Jlilnalot~nt . . p,artlclp~tlon;in H:ratapauUa ~e.UVIUe~ f"-cott\toen~e~ by h·or tn~dl~•l leal1\, ltfa rti:il anQofpotE18. !~1%1 Und'a 

wlll,galn or!~$& a su~stanlfal·am~un .of weight throughQ~t· the 'llfetlma oMM ··~~ng •Y•t•m. -

o;s)lrlba- any.anllolparad rMdlfloatiiins/eHaOgss .lb t_ho equipment within ·Iha Mxt thr1wyasrs: Thqra· era 

no modltlc~tions or change• anUclpatad lo IM •C(Ulpment requested wjl~lh.lbe n~xt tliree Ya•r•' .. 

--------------- 49 

\llOLSIQSS 

------------·----- ... --~--

000068 
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r •... - -· -· 

.i 

.,. 

---------· TIRR Mernorlal+lem'lenn··-· - --·· 

baserlba•lh1"'uad\bal·ne.:Sdlfy fot power VS, ri!a~Ual Wheetohalr! 

(Ju•fl!Y any ao.,;ssollantl<lh as po,wst lilt·br. roollh&) 

llnds laokii iha adflva movemanl, W.n~lh, ollduir.nrJe, motor.an/I poslurll/ ccmlfQ/ tq p/'6plj/ e mMuaJ 

Whealohelrot any.klna. Sha ls' Unable to )lerfsmi haroWn Wftl~lilshl/ta ahd d.M• lfal'fi~va ftJlllny or 

caregiver In Iha /!om• fo'.firovldr; rot f/er'mbUl//ly, /IJnqll<inal, ADI:, and pres~ul'& ts/leyl nelJdS. lliar.otore s 

pawarwh~aiohalr '!11th tlit llnd 8f~ndlne fasturse ls rsoommar;doeHor her daltfusa,. With a power s<f~M 

sys!aln of!flis kind, Lh1ds.wl/I ba.sbla·lo provide tot har nlc/>1111)' an<I fUitctlonal nM<l•·ID'aboalls it§ms 

snd.pedorm ADt.and 11aussl1old tasks In o ••IB anil Weallv• mannar. Site WI/I alsb.b~ •bJe.ttj. 

lndS/Jondan//y perfarm pressure "11/ef and weight Maring ll1rough hor·LE•, previ;ntlllg skh1 b'6ak<fQWfl 

and bane denslly loss, as Woll.os .•n/1apcl~gblomsah~nlco/ a1tgnm•n.t lhio~ghaullh•~•n.ffrs,bady on a dally basis, wl1loh helps fQ .proven( further Impact Oflipastlcl/y 011 /o//l/$ /n 11pi1gl1t postur.;,a. 

~ :;n;,;;'Vriiibie.10'0 era1~.~ manlleil olla\r av.en when adapl<id? Wl Yos.b No 

l~ self propulsion pogafbte but aotMW I• extremely labored? OY.es.@ l'lo 

/(yea, p/etfa• explain: 

I• •• tr prop~lslort passlbla·but con!l'acy to·l,rehtmanf l•Ulmen1 D v ... 121 No 

II )'OS, ple1'i;e.exple/n: 

Howwltrthe,poweowhoelohalr bO'opera°'d (han<!, chln, efo.)? L hand 

tf~s tfi:3..£1!'!!1!:...~~y~eted ~llh the proposed drive·oontrO!s1 Yea "'--.. ~~=- Ooes tliij c)lent have a~y oclldlUon that Will nilcesgJt~la possible change ln.aoces6 or ~,rlva confrol~w\thin 

tho n~xt·liVe ye0rs.? No 

la tfla·ol\~nl physically and me11tai1Y. capable cf op•r>1tl/l~ a ~owerwhaolehialr s~lely end WIUiY~epetlt to olh~rs? 

181 Y.e 0 No 

I.• tho oaregfve1 capable 'Of caring !Qr a power whe'elcheilr.and un'dats)andlnl) haw It operates?• i8l Yes 0No · 

Hew w1111ra1111ng·fpr lh•'Jl<\ll!ers11u1p1Mnt be>'!il~n1~11ahGd? :Untje·h·a~ t>'eWt trl2illn~.aj)UW.E!( wnoalGhalr 

With ~ln111ar dh'tfen~Jon·~n\1 ~ohtrol unlt~~urlnS M~ ~dmieOlon el 1Ne liO•l>itill. She ttas tlom6Mtiated·lh• 

ability lo safely oper.ate the eoaUng eystom In et<PIUhl w~ye, elevetorl!, ramps, r'1rwaid, ravetso, ·1urn/ng 

R;'i, up lo 9~0·, In crowde!;l•r••• 11nd 0\1 ul\aven sutl!!"'Jll • 

. ---·-·--------------·-----·----·-----------5 O.:_ ________________________ ....... ·-- -·. 

000069 

·-
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,. 

OflP Blgnetu e: -

1: 31..B' 

2:.S.1" 

"" c •.• 7 

-------. -.. 

.Ji'f!'> 

1'op Of Mad !tr bott<l'm of 

buttool<i! 

3i 15~ Artn.~lt to botk•m·ofbuttooks 

I 8: 18" Shoulderwlclth 

,. e: f1 .5' Arm pit to arm pit 

iO; ~-·-+H-"'l"-"w"'ldc::.lh:._ ____ --1 

11: 18.6' Olstanoe to bot!ci'n.df left leg (poplftaa/.lo heal) 

Ols~Gfi to bottom of J1ght 

I~ :oioplltaa/'ts he~/) 

Date: ~ 

----______________________ [!:__ 

000070 
Page 22 of68 rec~ved on 51iOl20131:33:06 PM ~acl~ Daylight Time! IOIO z Z! 0 ii 

... -···--·---··-

. p1\9slclan1T11araplses !ll[a: Oocup.~Uonlil · ·- · Dato: , ··· 1~:/· ·~ Tnorn IH · .,, 

PhyslolanlT.baniplsl'a talephono hu;;;;;;n 71a}79Z - 7~77 ----

PhyslJllan·l.i'haraplat •111proyor (naroa): l'hyelolan/TMraplst'6 addteae {work or e111ployor1addree!): 

TIRR Memorial Herro~nn 1333 Mour•und AVo, Hous!M, 'f.)( 77030 

. NP\: I 5 T~I: 

.. 

. Jw 

..... ·----·---·-·---------------------------~) ___ ----------·---------------------·--

000071 
TAB 4
Page 3 f or 68 received on 5120/20131 :33:06 PM !Pacific Oa~lght lime] (JI03l/06S 

. _ ·- __ __ AsJ/stlv11 Tsdi}\oJoW.-, 21: 161 .. 168, 2009 

C'opyright ¢12009 il~5NA . 1ss1-1: l640.Q..1J5 prlnv1g49.361"--onl1t111 ----.-----·001:-to. 1 ali&1nitoo4·:!oso311saii 

RESNA Position on the Ap·plication 

of Wheelchair Standing Devices 

Jullanh;t.Atva; MS, ~TP, , 

Ginny Paileg, PT/ Mlcilalfe 

Longe, OTR.-ABDA. ATP,' 

Jenny llebartrian; MSOTR:/L, 

ATP~ 4 Marl:( S~hmia;ljr, flhO, ' 

OTR/L~ ATP/"Btad bldanno, 

MO/Mike !iobloec·,:omi, · 

ABDA. ATP,' am! ll>"ron 

Rosen, P.i, MPT, ATP* 1

nsPort LLrZ, Ket'lnewl.;k. 

Washington• 

21ndepilrldgnt.Consultant, 

Mal}'lruid 

!lch!ldreti't Hospital of oenvet, 

Denver, C-o!or~do 4Mount Sinai Mospltal, 

New York, New York 

'University of Pittsburgh, 

'Pittsburgh, Pennsylvania 

~University of Pittsburgh 

Medical Center, Pltt5o~rgh, 

P~nnsyfvanra 

·

11nvacart1 Carp, elyr{a, Ohio 

•s~ JOs•ph's Children's 

Hospital, Tampa, Florid• 

Atidtcn «itrot"andence to J.ofi;sf\nn 

AN4, MS, R.O!kOIJI~ 11.G, 1/1, l!Othip~ft 

1 f22. Hun~;:r)', 

~-mall: J11rv1'9Ulttit.t:om 

All-SlJlACT Thi! do®f)lent, ~pprqved by:· the R•hobllltarion ·Eng!neorfog & 

A"iitive 're!!lmology Soci<ty.o(N~rth An1~tlott (l\ESNA) fipard of D!roctot• 

in.Maron Z0.07, ·•h<ris typlcnl olluioal •ppll0l(tion1 and. provlde:.cvid•nei> fro in 

the lltcta~. Npporting tlii> U$<·ofwh•oldμ!r •tllntfor<; 

KE!"i:WORQS PO'lie.t features, reltribllltatloti, stlindlng, wheeh:halr 

INTRODUCTION 

The·purposc·oHhls :uticlo Ir fo fh•r~ lypfcal ciinka! nppllc11tioft1 ns W•ll ii> 

provide rJ.vide.nce from d\q li~ro.turis supportlng th~ appUca'tiqq bfwb·~ctchalt 

.standing P,c:yiCes to. !lSSls~ ptns:P.tlonc.rt in.di:=cl.rlon mnlclng rind justJ.Eioa1ion.. [t _ 

is not i11tended to replae<! clinical judgtnont rclatccl to spoclfkelient noedi, 

'BACKGROUN~ 

CHnic11} experience 1ug~estS that whc~!c:h.alr. Ullc:I'& oA:C,n bxpm:icncc p;ih~fu~ 

problematic1 rurd co.stfy secondary compUcatltJ;u due to 1ongvtQnn· .sitt1us. 

Shtndlng bi llI1 cll"cc:tive.wa.y Co counterbalance Iru!ny oft:hc ncgatlvq affucts of 

constunt: sitting (Dunn ct al., 1998; Un~·etal.1 2001), Stn{lders fntcgr1\tt::d. hlto 

wli .. kh•lr hases erthnnce liie bcrrefltlal cltOi;tt oritntidlhg-slne~ they olloi. for 

more frt;quent, randoni, Jl'ld independent perforJnancc of'·sbUlding tlian among 

parsona who Use! ata:ndlng aovjce.! outside of il.whcdchair b~se. I.ntcgrtttlon Of 

this feature into th.e wheelchair base 1\lto <ll\11.b]qf st1n1dlng tQ enhance func· 

tlonal act:i\rjtJ«U. 

It b R:BSNA1s position that wbedchalr standing dCvice:s are often mcdkally 

netcS$~fy. AS: thc:y cnabla ce-rtaju individuals to1 

• bnProvc: function11l reach ta enable pur,tlcip;.tl9n in il'ctivitiei ·of d11ily living 

(ADL1:1) (t:.g.~ groo1nlng. cooking, ri:ilchirig rri¢dlc:ation) 

• Enhan<:< independence and productivity 

• Mnintail> vlt»I etg•n cap•olty 

' Reduce the oocnlrretni;.i:: ofuri11iu:y tmct in.fcctionf (UTis) 

" Mnintl'lJn bone mlnei:o.1 dendly 

o Improve cfrculatlon 

"' Tm.prove po.!i;iva r~ngc of tnotion 

101 

JI 

···---·-··--··---·--·--------·-·--------.§1-

000080 
" 

Page 32 of 68 recelled on 1120/20131:33:06 PM ~aclftc Oa~lghl Time! 

·····-··-- ---- ... ,,. Reduc~· <ilitfot:1nit! 1ni!Sclo t01lci (irld ipa.,"tfC11Y __ . -

· • ~e:Jue1,r-~h.e dc:cU¥ftn~~·nfp~~sur.e.s.ot~-~ . · · · ·--· ···--·---;.· Red~<e tire oc~tlnenoo of skeletal d•fbm>iti~• 

-----•·-81thanco psycliologloal we·t1-bcing- ···· ·· ·· - ·· 

Sp·eetnl ptt!cnutioO.$ nHt.St. be exie:rcl$ad when uti)lz4ii; 

S:tandcts is1 order. to :i.vold the risk of. infudeo such. as 

fcictures. A llcens•d medicnl professional (plzyskalor. 

oCcupat{oqal ~1e.i.·n.pist) l'nllit be h1volved-wi"fh auc:.ts.:-· 

me.rtt.;. prescriptlon, -trt11.ls-, o.cd trah'l-in.g 111 the u~c of 

the equipincnt~ 

Definltlons. 

A &tandlng 6:nture jnkgrnt'1!d in.to\\ whc:c(clltlir bd;e 

alloWJ the user to crbtnin a strtndltig Posl~on. without 

tha n~ed tO tl'a.risfer ttO.u1 the Whp~it1i1lit. A in~ohanicd 

m dcct.t~mechanicnl •yste111 irranlpulat<d vfa Ievm or 

the: wheeld1rt.i:r'S ccntrQl$ movies the seat iu,r£ac:~ from 

harl7.ont•I into n Yett!"'! or nn!orlorly do.ping podtlpn 

while mnintrlning vertlcnllly of tl\c l•gr•~t> nnd back• 

. mt, thu• Ol<tending tho blp an cl l<il•• ioh1ts.. A full voe. ticul ,stnndlug po$itiott Cd.J.\ be _achlcycd 4ir1;ctly from 

•ltting; througft gradu•I anglo cn~ngos fr6111 • faylnB 

position, or a cornbinntiori l)f t11e~o._pcsltlo11,s. Mo.&t 

whodchllir •landers ·•llow for full or portlal me11doJ\ 

of th~ hiil and icneo jo~1tl nud tull up rig lit or portially 

tllttJ positions. Wheelchair sbmdcts .,. •vailable 011 

manual or power wboclchoir bnm. Wb.colchlllt stand· 

ing·.dtviccit p;dclress tha· mod.lo~l :tlld fquctionAI needs 

described ht the sections to follow. 

Functiliinal Rea·ch and Access to ADLs 

Stnading addt 11. .dg:riifioan~ wiounc _of. vertical 

·ncc<;:ss. Sln.cc the li'~th1tt Jurfi\ce moves llil"o.J! .vertical 

. po•ltion, typkally the atno\1nt of addition.I -v.<rticnl. . -;· __ n.cicc.u cqual!i the User~s soai d~ptlt. Thi.¥ tdlows pcopJ¢· 

· to access ldtch~n ·cnbinctry1 light' ~witches, m.1ctowa~1 mirrors; sinks, bllngc:r.s, thermosb\ts 1 ntediclne cabiiiets, 

and· many othw· surfaces to cnhrtnce their abilities tO 

p~rfor.m ADLs, dc.pendhlg on th~it μpper extremity 

(uncfiou. An ·iittc$rnted whcc(chnir stander system 

11Uows: for moving about while in n .standing 1;osition, 

ttnd standing cnn bcco1ne lln iniegni.l and func.1ional 

prtrt of the d11y 11nd the wcr_ci\n·pcl'fOnn \l vllrid~ of 

ADLs while !11th• stmding.position, combining func· 

tlonal ond inc:dic:al benefits. A sttt11ding podtinn ~n 

b~ a~suJncd as needed, both for indoor nnd outdo·or 

J. Arva et 111. 

.. JJ 

\ll032/0oS 

acμvltl~t .... tt ~at\.'.tti~ productivity and in.tpgra.~i~n 1\t .. 

w.ork, schqdJ1 chu~h, .. or e~!1a~ce il)cjdp¢d~Oc"> 

such nt wh~n .•hoppinr for grocod/,Cllob1il)•likJo 

peifeQn at.anding from one1s-wheolohttir-1lho 'ftlln.ii'rli?.¢s _ 

tra.ntfer.s.- thiircby .enhancing: n~.f,fty, cons1qVfn-g.ener-gy1 

~nd reduciri~ dcpen.d4:rtcy. Ro·s-eJu:ch suggi:ists. ~hi\t \n 

·l\i:fditlon to·¢::<petu<! und Jnck Ot·a:vtareocss, the to.D.jor 

r1J:as9ns for l\Ot using stO.ticin11ty standct~ for wheel~ 

chalr users with spinol con! injirrJ., (SC!s) '* time 

constraU\t.S, 1Ack of asiistanc:1 Mcl!or lack of spacu for 

'" oxttn dcvica (Eng el .~, ~001), 

Passive Ranga of Motion, 

Contractun;i$ 

Standing oxtcntls the hip.and knee Jolnt'to·provkla 

poiltion <h•n_go, Aulnial studies h•ve shoWl'I th•t mus· 

clodlxdd .io ~ !lo,~~ po•ltlott resulr ill incr<llS~li c6fl· 

tract\lras. of the jdint11 cspcclully wb~.fl .. th¢ ·bones l\re" 

sdll !lfOWlng (.rlUd<l ~ Uhthoff, 2000; Trud•~·~' •I., 

19.9~). Mony pcop)c in whcolohal" h•v• Hmit•<f acce<s 

to thc.tapy or c;:ireglvoroi whQ cnn provide·thd ucces'ary 

umount.ofnng!rtt slnndera lntogt>tlld with the wheel· 

,hail' b~;•·nllow. thw:n to perform this l111part;t;\t nctlYitY 

6tt thelt own ·And with l\Jghe~ frequ~ncy, S~anding, 

tiowever, ~hpuld not be caniidarad l\.'i " .wbs·iitute fbr 

therapy. 

Vital Organ Capacity 

· Dudng standing,. the pelvis tends to M!lllfn:c A. ntoro 

;lntO:rfor tllt or nCutral,p~sitipn,_ 11.lluwlng: for.;in incre:uc 

lrt lumbnt lorddris as comp111'e.P. ta sitling. '!his in htt1t 

helps cstabll•.h • bqttor a11gi1mcnt oF the' wine ~,,,;1 

extend tho uppo.r truhk, Bxtemion of tho upper tmnk 

results in reduced pressure!! on t,h.e j11renia[ org:o.i-is~· tha:rdby 

enhonchig re!pkatoI)' und gutrointesti11!11 cnpncity Md 

functioning. ·Jhls cl\n preve11t oi: delay mo.ny of the . 

s-e:eon.81uy CQmplicatioll8 so oftdn seen 1n whec::lch:1!r 

USC'(S, 

• Rcspfral/on: Many users c>:peri'efice in1provc'd lung. 

capacity when st.anding oftcll. Studies: .hnvc qhown 

th.at those who stnrid frequently in ·stnnding power 

whi:.clchoirs have l~sser or deln7cd o~nri:nt:e ofrc$• 

pir~tOry complication$ lll1d improved resptrotory 

vol~me (Eng et al., ZOO!). StAnding aon oho help 

reduce congestion and cou,e-f1ing (Stuinsby a; Thon1ton1 

199!1), 

·- ·------ .. 

--·-·-·-----·-···--·--·--~------ -----------6 2 - ------------------------------- -... 

000081 
J11 

·.'.')·.·. · .. .,_ 

i'·-

Page 33 of 68 recelVed on 5120120131 :33:06 PM [Pac me DaWglit Time) 

- ·· · -- ---_. Gt:11lrfJl1u1stimJ ptablems,• Stttrtdfng wha~lchain· u1:1eu · 

ali:o cxpe-rfoncc: IC3$1!1" ot di:l<1yed occurrence of g;i$• 

lmlntestittid·compucn·tioiJS,--ror-c;amph; Vlil 1mp~ove- ·--· 

--------1111.ent lh-jplstr1¢.c1nptyintt-(Dutm-et 11!.1 1996i llng.ct11l,1.,_, 

2001). 

BM)) leveI11 will continua: to decrcas<? and/or roturu to · 

pr~..welght--bcurlng valuc1. 

·While sbltionll!1' st1ltld"1>· le<sen th• lo" of .BMP, ----

whcc!~hair !ita~deri f!lil.)' ;~a.uaUr. .e.H_!)iinnt? .. ~Mti:l· 1Q~~---····-· .... ··- __ Utogcther. given their ability t(). provide dyUnn1ic: w~ig:ht 

• .B01{J(ifim,ti-Ct1J Some u:er.s hi"/o axporlenc~d Improved 

bowar rtgU1arity, reduced constJf'ltitlon1 and. lc~c.r 

occu,r.ninc:e of ~c.cidental nnd unzegukitc:d bowel 

movements as- 11.eonscque-nc:e of uaing-wheelch:tlr 

5toudm (Dunn ct cl,, 1998). Ellrrtln•tiol\ Qt chtonie 

cons~pntlo1t and ilgniilcou.t Taducclon in howd c•v: 

t:irt\e liavc all/O been. shown 11s a t~iJlt of &.d.e!Uent 

mnding (B11g oh.al., 2001; Hocni~ ot al,. 2001). 

C~hronic constipation can lea.d to bowizJ. obstruction, 

a dangq-ou.s r.ondition often r.i:quiring. sut~cy. Unrcgu-. 

hittd bowd movement; can lead to fecnl inco11ti• 

11.c11i;e ·at·t1 ·tri:n" WliM the client 01111.,ot b4 .clo~ecf. 

by 11 ciin:glverJ lncre;uslng the ritk of daY.etoping pressure &-orc.t. . 

' ft1,R'~#Sld bladt!~r tJttp~itt,rt Ustr.t of !ltundlJtg dcviC""cr 

h•ve rcportod tlint they oro ao!c to empty thoir bl•d· 

d~ra morq completely tha.11 prior to ui:ing tM device 

(Du11n et nl., 1998). 

Urinary Tract lnfeetlons 

UTJ& arc t11e- third most &equcttt complk.gtfon for 

dien.ts_ wlth SCls and A frequen.t sr:.condary co.m.pJi.cn· 

tlon for nutny ol:hat' whei;{chair t.u:en· (Me-Kinley 'et al,, 

1999). Pcolongcd immobility ""U$c& hyp'¢rcalcemla, 

l11tir(!~sed udnary calcium outp\1t, and ~lso rc?ucre.'I 

bfadder emptying Qnokul.: et al., 1966). By rodudn9 

tontributing risks, ttandJns· ,vbedchair3' 'h;ive bton 

shown to reduce the occur(enc<:. of liTist whii::h could 

1,.d ro kidney infectioM (Dunn et al., 1998), 

Bone Mltteral Density 

Martywhci:kh(lfr lft!:rn expei;icncc significnnt reduotion in bone 1nine.ral density (BMC) due: to the lack of 

wcfgbt b~ring In the low-er extre:mitieJ, In f11.ct, with· 

out gravitational or tnechanical loading of the &k41etoJ11 th12r~ is a rup{d nnd morkc:d loss of bond. 'This 

results jn osteoporosis and tl.sk of Fractur(l$, ReseC1tch 

suggc$h tli~t weight :bc-adt.ig il i;upcrior to .nutrition'ol 

ftippleinetltt in· preventing BMD IQ$$ and thit the 

n1cch11nicnf loudiog of the. bones should be dyn11n1ic 

for full proveotion of BMD lo.,, It also appcors tha\ 

wlth discontlnu:\tion of the weighC .... bearlng programf 

163 

63 

beerl.ng through the lower i,:treruJtfos .. Po1~u~(\rlotU. with ~ 

vru:icty of'ditJbilitJci luv• bc<:n •tudicd for !ois ufBMD, 

such ., children witJ1 mob.ml· pol<~ Ot •pin• bifido, '" 

wcl[ ;,. •dults wltlqμ,iko, multlpl• sclerosis, and SOis 

O'hompsori ct u{,, 2oOO). Eve~ lf BMD. lo5J' has n•t ~et 

occurred. In a u~r)stAnding CllJ.1 ho·an·eff'ectiv4 rhaa0$io 

halp prevent tlils •~eondruy <~tnplic•tion.-

• l.lm'l[BMD1 Review st111;Ues csragl!sh the dir~cl rein· 

~0~1hip bctwcon weighrl"'3ness •nd-lou of'BMD, '" 

wi:U as the rcfotlon.'11ip .betwcc.n oste:opo1oa.i1 ttnd a 

high n<k of fractur" (Ehrlich & Lauyon, 2002; 

Martin. & HQu~ton; 1987; Martin & McCulloch1 

1987). Studios· with a.morututs and P.•opla ln bed 

rest quantify rhc negative e.fl'act of wo.ightles!ness 

and lack of weight bearing on BMD (Lut-z ct al., 

19$7: /v[A2ess & Whodon, 19831 Whedon, !982, 

1985; Whedon 01 el.,.1976), This oan be os hi~h "' 

3 6% Jo.u of the cross-.;ectionRI art:n. o( JI 0011 .. w~lght~ 

hmfog bone wlcl1i11 a month (Louyort. <I al., l ~86), 

ln bcdr.est, the average urinary- e1ilclum lo#.'J nt tha 

penk Ls •b~ut 150 1'lg per day, which con•sponds to 

O,~ry, of totlll body calcium (Deitrick et aL, 1948; 

Doruild~an et al., 1no; Hangartner, 1995). l'or people with dli•bUitior, numerous stnd!e's.poifil out the 

bencdlt:s of &cque11t pudve st4hding and wei3ht 

baaring/cxcrclsc for -BMD {Go!!-mv.~r~ ct al., 1984; 

l<oplon et af., 1978, J 98t: Kunkel Cl!!]., 1993), 

• Prar:fttrts and loss ef indtpimdmrn Loss of HMD leads 

to osteoporosis nnd the consequent rfak af&ncuuc$. 

Articles on children wlth os:\-eogcnosis impr:rfecca 

roc:ommend frequent $hu1ding in childhood to mdx· 

imizc a.duHhood independence by tru1limlzina froc· 

tui·e; nt\d the likt!lbood of broken honer (Biud<t .. 

et •I., 1984; Block, 1981), Many people with dnabill· 

tics often hcttl slower as-well. FraclUre$ mriy Umit Jbortand long·t<nn functloll. 

• Suppkmm/J: E'lidenco suggc.<t• .. th•t while appt¢pri· 

a.ti: nulrltionitl 5up:plcments n1ny reduce cafdwn loss 

frotn. the bon<>, m<chauleal loading ls •upetior to 

:iupp{ement.s for HMD tualntennncc. (Lan.yon e-t al., 

198g), Dietoiy chongc" such " !J>CJ<!a<cd intnk• of 

calcium nnd/Qr vihunin D1 have: not p.rovi:!:n ~ff'cc· 

tlve ut mi1Un1i:dng dfaus:cd bone fo.s:i (Sin~ki, 199-5). 

Wheekh~lrStandlng De\lfce.r 

····---·----------------------~-------·--·----·---------·----·-----------·-·-·------------~--·-----· 

.. l 

000082 
i • 

Page 34 0168 recclved on 5120/2013 t33:0o PM ~aclffc DayUghl Tlmej 

'.Mcchruii(lttl weigh' /adtilng: Living bon·ee co.nJt'i\htly ....... !OaQ.ing) (Fro~t. 1990), However, long-term routi1)\l 

1tdapt tharruelvc~ to· the tn.echo11.lcal "ibrc:el npplied londing Is. frnporlaitl! in maint~iu.iua~ bone den~ity; 

-------to thom, ~nd thcicsti;ucturd( dltootly..llnhd to their··· · · -And-althout<li bone rnponQ• to mecbanlanl lonQ· 

--------.::wd~ht-b~rlng 11ctlV1ty nnd forces Qccurring duo lo h1_tt:}t_!.s .. ~~~ie.r t9.l.C?s~ μ,_9n~.-~h.r~~S:J!5.r._a~!i~l.9'_~~ mOVemc'ri.r a"jilin~f tCSl3tb.ni;e -(Simkin &: ,flyaloit, · · io ir~ln m0r¢ t})rOugh changcs lfr .fi.,ncH6nuf Jq11tllhg.. --

l~90). Welght:ba<U'lng aGtlviiy..ca.n be. thought of ~s Whe.il we:i~ht-bo&ring:. e":S,eJoisC! it }j:ot contitH1t:d1 

•uy •crivlty thnt is done while upiigh~ reqiliriu; tho bQne mas1·reve1tt to ptctr•lnln~ Jovel; (D•lski et al., 

bones to p>ttinlly or fully JUPP.ort tho body'r weight l?8SJ Dtlnkwotor, 1994), Wlth •rnndUa intCJ!1'l't•d 

og<t~\it gmvlty (Jlotlnlc:k, 1994). lmpact4oading, wei1;ht• illl-O • wheekhair bt>se, th< useds ttot dcpondanto\1 

bCltdni activity thorefur~ Jnvolvi1 some impact or clraumst:tncas (such as carcg\vc< 'VRli•bttity) ro. conlQrc~ being 11'i!U5utllted I<> tho skeleton during woight tinue standing-, Cousoqu~tly, m~inton•ncc of a 

be.iring. Stmding pt0vide.s me<bonlcol loadlng·thtough standing program •!Id hlgh01• fiequen11J1 of N1Rndb1g 

the ·1Qtigitudlna.l ax<!.s 6f the !owcir extremity bones:. ~fe mo~ llk~Iy. AdditfQnally, in~qgrated ,11h1Udeni 

Whan the body is upright and extended, the bonot •!low· for stnndin& noarly aily cln\C for aity l•ngth of 

of the tOwor exrr~mitl~• Ca.tt)l' tho antirCJ w~i~t of lim.c, nnd thcreJort! w~ight loading is more l,lkely to 

fire body, ni~d thcl'efore loadh1i· is most efficient. be of nndom diitrlbutlOn, whl1;h Rppet1rs ta bt 

Sinca tho lower exuetnltles nonrlnll:y carty the entire: superior in "BMD loss p.rcvcttUon.~ 

body's walght1 th(o/ Rt'C. the most ptone to bone 

de"e"'"'tion duo L<> rcducod or limited woight ~ei!rlng. 

• Dy~dmic /a#i"3: l'urther studier clarify th.t stnnding 

'ho'11d be dyn•mlc Qiighor multltu'de •nd vorlcd 

magnitude) in order to fully pr<vtot Jo,i of BMD. 

According to chc 11ci.enti6a Uternture, Static Jondlng 

b lo,. effieict\t th"1\ dynamic [o~ding Jn preyentlon 

of BMP lo" (Frltton et al., 20001 Lanyon, 1986: 

l.1tnyon & Rubin. 1984: McLeod et tll1 1"9.88; Rubin &; 

L.;nyon, 1984). A .recent rtudy ot chJldrcn with 

disrt:bling uonditiana: fuund tha.t o: 6-1no11th stnnd.ing 

program wlth a statiomuy staifder lrilf re•ulted in 

UMD reduction {of 6.3%), while utlllzlng'vlbroring 

plat!::I underneath the s:t"i1.11ders 11ctunUy h1cr1Ji1.setJ 

B!Y{P (by ll.9lfo) in tho subjects (Ward ct :11., 2004). 

Thi.s i& of uttno$"t impol'mnc:a rc:gardirig standing 

wltcclch.a.irs1 ,thice they offer dynamic lotdln.g in a. 

v;:u:ie~ of ways. Wh.en udns: a mobil(I wheelchair 

bMtJ during ~t11n~ingo, vibratlon occu{S due to ·the 

1novement of the whe.Jchair opplying dynamic 

loRd$ to tb.e bQ11es ot'lha lower extremltio~. In addt .. 

. tion; sm.all obs:tttdcs (~g. 1 carpet e.dges,'doorthr~h· .. 

. olds, tilo edge,s) prov'id< dynllmia inp\JI when the 

user drlvc! over tham. Standers integrated with a 

wheelchair base also allow for fr~quant lo<l:dlng ot 

lhe ban<! throughout tho day •imply Yia parUal 

st',\nding. 

o M1t'ntC11M¢t: of Wdigf;t burn~ Pot tl1Q W1Jtght-beuring 

c;ccrcUa to be. elfective1 tbe rnech~nical s.trt:sR placet! 

011 the bone 1nu~t cxcood the level to which tl)c 

bot1<i has l!do.pted (i,e.~Ghort pctiods ofin.t<..-nsc loading 

cl\n produce. more new bone than !ong~tcrm routine 

I. Ar..;a el al, 

Clrculatlon 

Usett have Rl!lo axpe:r.i•E!nccd imprOV"cment in lqwe1r 

extrCa:dty cin:ttlation as a conBCqliencl:! o( ut:ill!i.ng- a 

wheelchair st>mdor (l\)ig o~ al., 2001). Ono benefit i• 

reduc~ swelling in the lcg.t end r~ct. 

Whccfchair staU:dt:rr al~o ;ld in rtduoPon of eX"Ce.R$ 

111uscle tonei re.Se1uch indk~t.es th1u muscle Stretch. 

combined with weight loadh1g redUc.e.s muscle ·tone 

more than stretch~ alone (32% vs. 17%) (Odeen & 

°K'llUts!bri, 1281). Some llSera experience .tone reduction ·in their upper extremities due to better skalc.tal 

alignml!Ilt in Cl 4ts.nding poritf.on. 'fhi!J _may trnu~lara 

!nto improved s~1;ch o.11d b~tt:cr hru1d and ann function to perform ADLs. Tone rcductlon can improve 

comfurc, mlnitn.lzc frutb.er rnngc of.1notlon loss:~~. 

hnproV~ l'uo.ction~ a~d ~onscr.ve ~ne.rgy • 

Spasticity 

Studies .show t.hat standing whcdclu1.ir uscn h1tvc: 

oxptlrionced slguific:znt reduction ln. spa.sticicy· (Dunn 

ct•!., 19981 B1>g et •l., 2001). 'l11is helpv with lt>nsfort, 

can aid ln better $l~¢p, redQt:c.'i fatigue nnd paih, and · 

hnprovas posit:fonlng in tha whaol.chair. Stnnd.ia~ hns nn 

lmmc.diatc and significant effect on .~pRsticity (Bohanrtotti 

1993). 

...... _______________________________________ 6.,4 _________________ -·----------------·-. 

000083 
@035/0SS 

Pj-e~s4re Sores Additional Benefits 

When fully Slilttdid.g, pteutiro fa compli;!:tdy ft.)icv~d · Additloti.al benefits ofutilizi11g: ;:in inregra.tcd whc:doff the U.:htill ·rnbctO~ltiC:11 (rfi). HCrWCier;· WJleti tJJiW.g----~-bOli irilildliigsys~d.liii.ciucreD·ut·Are·riot limited· ta:·. 

ot rc.l'.!Ui:iiJJg ... the~Js.only.parHnl rc.dfatdbuti011 ofpre.s .. --·- -···-· - . -·· . -·-----·--·- . ··- . . . .. ____ _ ------:,:::~=-urtdCme1Hh the 1Tt (Aissnoui et 11.I., 2001;· Jiobson, o flatig!.I~ is 1cducad due to the benefit! .mentioned ---····---·· 

1992). I?reSSur~ ulcers are the.prlm"Rry camplic:atioh for ·earlier. tb!Jrcby prolonging tolerance hr tcrnu -of 

p~opfa- with SCls· and m11ny other 11dults who .sU in .stayh1g in the whcdchnlr for lot1gcr p.eriad$ of tinl.e. 

whaelchitlu .aU dfly long (McI<!nli:.y et 11l.1 1999), Th-ere • Samit mdfe usei1 cm use a. public urtnal iud¢:pcn- . 

1s evidence that tucri hitV<f suffered Fewer prcuurd doll-dY M oppoSJ!d to traoNfurring to JI toiltt or u.sJng_ 

-~or~s whl!e using .1hlndan or jntegntted wheelchair cathetcrh:ation. 

1ta11ders (0un1t •(.al., ins: Eng, et ttl., 20011 HobSQl1) • 1'ho S)eeO fot attarid,nt care is "educed by Je.,~nlng 

J 992). the 1>ttcd fQ transfet in, rnd o(lt of the .wlml\':h•lr 

Skeletal Deformities 

Clin1¢al .i;axpericnce: $uggests th'at: ~ten8ion of the 

uppor trunk and proper •lignment ·oflhc hlf during 

stnnding help delay 1rpic:nl skelctru dalbrmitt<s often 

1oen id pepplo who 4/t In n wheelchair for long periods 

of cima~ such 11s tlxed posterior pelvic tilt,. lcyP.hOd$ 

and.icollosll of cl1e spine, and windswept deformities 

of th~ lower oxiromiries. Diirlng standing, tho hcod of 

the femur uaunlly ends lip better scntcd.ln the acetabulum. which ·ix imf)Orf"ant cspcdalfy for children to pro· 

m.Qte healthy skelet.i:l ~lig,1tinl!nt us well <ta to promote: 

proper deyqJop1nent of th(; acetabufnt sockcti; 

Community Environments, 

Vocatfonaf and llecreatlonaf Benefits 

Intoguited \VIH~e:lcha.ir nandw c11n. b¢Uc.tit μte:tJ in a 

varii:t.y of ~orumUJ\ity settings, to e.Qh;ince rheir inde: .. 

pcndc1~cc1 improve·v.oi;utionil .1cdvkle.$', ~nd t:nabJe 

recrc11tionaI activities. E:camp1e.9 "include but ~re not 

llmitod to the following: 

t lhtpfoved ibility to roach big.her shclva!t In grocery 

stores aiid oth~t shopping (-ai:;illties 

··: .:· .. ·.-- ; AbiflLy tO. access vending ·-rnnchfnc-$; pnyphanes1 

high cicvRtor buttons, coffe~ shop count~. 4nd so 

forth 

11 Improved ability to stund up to accoss fur mnchines. 

dr;i\vcrs, client files, nnd other ncCessides tlt work 

• Ability to be amp!ay•d in certain jobt !bot need 10 

b• performed rrom • •touding poiltion (e.g., hotel 

rccupHarrist, clcricnI or medical workctr1 h<ilr itylist) 

~ Enhanced ability to cngnge in r~cre11tfo.ca.I ac:tiv(tic: 

(o.g., 'tanding up with othm in • h•ll g•ine), 

165 

m)l Improving the RbUity to J'dllge< ind'opendcntly 

atid peiform ADLs. 

• Back pain 1U1d rl<k.of ln)ury tte r;oucod •mong <~•~· 

givers by mlnimiztug the amounr of ttaus(cr.t they 

need to p(!fform. · 

• 'Partial &hlnding provlde! ru1 :interiorly sloped femur 

posit!on, whi¢h can tr.an.iLitc intll a better peJvic. 

align111e1tt and enhfll"lcCd lu111btU' Iordoslll'. curucal 

cicper!.,,co stl8!J"" thot some oli•nts find cl1fa po•ltlon l.rnp1ovl>$ their alert11"s :111d/or their upper 

cxtr~mity function. 

• Mnny child~ who ullc- n1cblllty aqulpme.nt throughout the day ur~ on intensive ttandins:.progrnm,r, They 

ofl-o11 hil.vo a .!ltandcr at: .school J\tid one: at honw.111~· 

grating st:<ndini Into tho wHwlcMlr hMe roducos U10 

necessary 1U11ount of dC]llipmcnt ;sud ensutcs moru fre~ 

quo1~'r and Jndepci:tdeJ\t inil.iation: of sttmdins:. 

• Stnading up with • tilt t:ib(dunc~on (gn1duo.1 nuglo 

chnnge Into upright) m'1)' help nllevfate problem• 

wlth orthostatic hypotensfon, i:speclalfy afior prolouged b•d,..<t, 

Psy~hosodaf fndic;atlons 

A .~l\tnding-posidon um le.ud ·wheelcbn1r users 11 h<.!ight~ 

ened f!!JU'e of confidence and equoUty by enabling eyc•to· 

aye couversa.tio11t \flth. ~h1J.nondisablcd society. Many 

everyday nnd special oci;(lsloru in our S"ocfcty require!. 

sttw.ding, tuch ns cicing of the: Pledge of Allcginn.cc nt 

Jichool, graduiulous, wedcfing.t, demon!ltration'I, introduc· 

dons to- other people, and raLJgioiu .~crvicc.~. When fl 

perro11 is allowed to stiind with overy0l\t elsa (via \In. 

int~gratad whoalchair standing devlca), there ir • much 

better sch.sc ofihtegration i111d the di&abjllty b~om<!s le-11$ 

vh-ibJ~ t~~c11te:em ia enhanced, acceptanc~ by oth!!J"S' i.s 

perceived to be higher, nnd depression. is oRco rcdu(l~d. 

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Co.ntraindkations lo"?"''"., often" the""'' con tolerate oomfort•bJY·-- .... 

fri ipfte .. Ofthe rlumCi"6u#·h¢1tcflt:J;n1:rudingwbeeJ------~?-~.~.:1?'':.asc ~~ he~-~e~~~· Stao~an l11~~r~t~~~~~!:> · 

-------•ch.nir..rnight bo cc;intralndlcnted_w_icli.Qut appr<?eriatc w~:el~nlYO~$eS allow.fat StJOcltanr:ous and frequ!l.nt 

ttsse~$mcflt. Not evc:rybody is i\O Rpproprii\te c.nndi·. Ut hzation ot s~11dl11g. 

~11~e for :rondjng. Sorn«J contralndiantious and pracau· 

tlo'JU include boc '""no\ Um Ired to: SUM MARY 

0 Exlning r:ontr1W11reJ: 'rhe, client f\'lay b¢nefit from 

P.•rtial weight bearing even lfhc ot the· already ha• 

fixed co11trnch1re.s of the lower 6.Xtrum.itie~. How· 

.cv~r, the ,11nount of extcnsio11 may ho.va l_(> be lhu· 

itod mecl1"nionlly· or<lectronically, e&poqlally-in the. 

cm of a ~lient without sani;;ltion. A wheel(:b11ir 111.11ndei 

is 11 powerful deVj(te. and .ml\.y i;:nu-110 hWJi ir atlempt-< 

lng to overstretch c:ontrnctcd 1nusclc:t. 

• SMtta/ defomiitic11 fiath the >ltti11g •o<l the •tondi11g 

podtion [lQYe to providi: op1>ropr.iati! 11\lpport fot &t;t .. 

bility nnd funt;tio1i,. so sp<1:'4fo.l accommodntioni n1ay 

hl\ve to be }UovJded for people with significant 

dcfo:rn,iti¢5!, C$"pcclally it' those defo.ru1ltll!~ ri.ra not 

flexible. s.kelct•l •lig~mcl1 t •hould bo c<refully 

l)bSc:rV9d while tta~1;Ung. 

• t..rrk Iii ',,.,,r"W ""''"''"'·' rr the ~uent h" not b«~ .stnndlng fur o. ~~11i!.ica_i'lt amount of time (s:cb.i;dulcs 

vuy _by perso1' and ·circumstnnccs)~ rt is n<*uaty to 

o{;ta-ln a f>b.)'&tcian1a apptov:J t1nc::i t-Q.,t 11. 4llu1<kr ti:i a.ucs.s 

siunding tolernace. Prior ...m[narion.s mi!Vit be wnr· 

.r"1ltecf, •uoh ••X-ray• $ld bonedeusity "'""mL11t!, 

• DMD WISJ Bxli!ing llMD Ion and ost<bpotOlis might 

t11u!u1 fractures if attempting to stnnd prematurely and 

. withouta wcll..lerigned, progro,.ive sta1\dln~ profPin. 

• PcJJlurd hypolm..sloru Blood pre~uro arid diziln<!4i 

sho\.lld ba checkc.d while: 11:taoding up1 especially for 

new eliants Ydth. recent iujuric.3, 

• Suualsbrar/11g1 Some •mount of"""'! sheru\ng might 

occ.\lr while. stnndifiS up or .,ittjng dowui: attention 

1nut:t be pRicl to J:kin intcgrlty in tlte M.cr-Jl region. 

• Ad.'tpli'uii ar ~a.tto1n statr.'ls,g1_ Standing syst4mc will not 

work widt ortc-p1e.c-c 'seating: .ry-stams (11s the sen·t tci 

bnc;k i'lngle changes) or hishly contt>urcd ~eatlug system$ doe to shl!nr. · 

frequency of Standing 

Ft'ttquuncy and duration of 8tatldin$" iv4tin4s iro 

rccom.tne11de:d on· an indlvldunl batii;, l'ht:y V'J.!Y by 

tolerance, .fatigue, !eve;{ of eUrrent BMD, ::.nd fi1natlor1:1I goals. ln ~C:ncral, sto.11dh1g is recom1ncnded u 

J. Arla et aL 

It i9. 1'IlS)iA'• position that wh<~lchalr sttnding 

derlces ore medic.Uy bimencial fru wheolcbolr """" 

by cnabl~~ tl10m tQ roach, il~provln~ AOL nbilitics, 

~hha~lng. 1ndependcnc., 1111d prod,iJ.ctivit~ maintnin· 

~pgvitttl org411 capa~iJ.Y, boo.cs minernl density, circul11· 

tion, and range o( tt\Otion1 reducing torte and spMticlty 

•M th• Q<curren.~ o( preosur• sam Olld sk•letal 

dcfo.rmith:xj and enhnncing p.sychoso,cial weJl:buing:. 

CASE l!'XAMPLES 

J, 0. ;., n 19-Y«tr•old male with spastic atheroid 

quadtlploglc cerebral palsy, H. h;u been drlvlng n 

pawcrwheelchait foi: 1nobiUty. sine~ he WtlS- 6. A power 

wheelc~air with a Sh\1!d{1tg fiin.ture w1u pri:scribod to 

bim. d.ue to the need for ffeqnent standing, func:tional 

go11li; ·t<'> enh.il-t1C~ independenc:.e::, and to reduce his 

mother's bac.kpitln, which ih~ developad due to fre .. · 

· qtle:nt tri1tt$'£ers. Afler 6 ro.onths Of UlC. a mnrk<.id 

hnp.rove1t1.e11t wa.~ noted in his upp& 11;it:ttcmhy fimction, his speech and m•llowlng, i• well •"11is cotn,!ilrt 

and tol•rance with respect to staylng Jn th.c wheold,.ir 

Rf[ day. 

huir la • 65")'¢ar·ol~ man with rnultlplo scle;osis 

(or tbn Jast 1 S yca.r.s, On initilll evaluation, he WM 

cxpc:ritu1cing signlflO\ntprobli:ms· with low~r extremity 

spnstlcity th-at interfered with his ability to ait h1 a 

wlidekhalr-ond to be transfcmd with the .. tist~nce of 

hi.s wife. He wiu ui1lng 11 manu11l whciilcbnir with a ihn~ 

ited scatiri& system and wns developing 11 severe 

kyphosls of the splno. He olso had issu .. with bowel 

· •ud bladder con1r<1), low(ll'.~Xtremlly edemA, ond poor· 

atrcct. Following co.refill asscurnc11t and an extc:ndvc 

'Uinl of a st11oder1 lie·Wll.$ p.i:D'Vide.d wi'th I\ po~r wh~ol~ 

i;;hait ~quipped 'vitb a pl\s&ive sbtudar as well a11 tilt In 

'$:pt1cll, tecliJting backto~t, and elevn.t1ng.lcgre$ts. A-t il 

6 .. montJi. fa,llow·up assessm.crtt, his teport<!d standing 

fo\lr fo _,:ix tll'O.C! pc.t dii}' for 15 to 30 1ninutas, He wns 

observe~ to have !liguiflG:imtly qec:rerued lower extri?rnity 

Gpl\Gficiey tu ·tho pQint wher~ he wtu no longer takhi.g 

aucl-spnstlclty mcd.icntlon. His wife reported thl• !11rther 

made tnnu.forring him safer ilnd .l'nORi manageable, lt 

16G 

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000085 
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;il.~o nllowt'd him to hnve ilnproved bed mobjJi(y so llohamon, R. W. (IQ9.~). illl tohlt nancltny for 1eduti11!J J1u1t1d1y ilttr 

· --·· thot l1!ll c9llld get 'a full i~ight s sleep, MO(COYdr, the.re . ~~/~~1';t ~Jvrt. . .ArrJifva$nfPltydC11/MtJdlellJr.:S:Rcltohll(llll/1Jn~1-1, 

-------.llW[!!;_a.> no noted cde1na ht hi.!ii.l'lWe.i'..!}-Xl:(croitie$'~and...hc- aonnre~.S.L'1~9it}-h~O$tl!:d~hdno'll0ak:ol'dlas1T~)kiP.vhlls:hll1g. -

reported far fcw~r bowei And bJadd~ t.t.ccidcnts td the OAIJ!::y, G,.; StotRe, Ku Et\Sill'\I, A, S/a1opqlgky, !-~'lder t. ~ .• & S.lrgii, ~:I -------- I ·. - ' . ·-- · --(:l-981!J,:..Wel9ht·b.e<1rfno cxor~h&·tta.ln.lng- iln!f·h.lli'Lb.fr b9ht miner al o nt wH~ro he .,Vt1s c.Om.fb.ttahle g:ohig out Ul the com.~ ronlenf ,In postmenop11usal \~m~(I'. Af}l1;1h at tnCtfNf Mcd/'1/ia, 

.n\unily on n weekly b:t~h. He demoiufrl\tUi.1 il'riprovcd 108, 8~4-s'zs; · 

b '(' '· ·d •-- ·d'ffi ..r DMrrld:, J:, WtJo@.ri, G., !ft '5ll(:i(t1 ~. (f~). fffed$ of ln\fllQfxliza1f0J1 a ~ Jty to nmcw an cnrry out ta.sK.:t ar. J erent SUrrl\ce \l?¢!1 v~rk,i.~ rnmb.Qlk and p!lydploWc fU(l(;tlOnj o/ noumd fl\Oo, .hm~bt,, Wl\C observad to be able ta slt- in.ore Uprl~ht . AJ.11ei{'3nJownMofM1dklTJo, 4,"3, 

with. less kypha.rl.s, artd demolistrat~d imprOV!!d affect. OOMJ.dsoJ\ c. L, Hl.fl*Y!.s. h.,;vO£Jd, I. M,. Hl!l.tttJcc, R. s .. S'1~B. 1. H .• & 

M D • J6 'Id I .• .ed. .i· • f ... ~Mitani o. ~. {1970). enact of pro!Ol'gitid lSed ret.t on Q1;1n1 min· r. . 1.:s a <iYCRNJ m;i ~ vt1Ul a ~ui:gno.na o tc~- oral Mefabo/Jqn, is: to1~. 

r:tplegia due lo .a C7 spb111l cord in.j\lry.. Ha M the pri· Dtlnkw•{er, e,. !.. (19!1<1}. f994 C, H. MCC'.ioy Re.~eatch luc:tvhl': OCH · I · f b d k ~1 ph}ISl<IM activity play • rol,. Jn- pre1111r1trng ·atteoporom·1 11.ese1rch . m.nry ciii:eu1 c~r a lW~ youn~ oy$ a~ wor ~part r;intC Q!R.1Wftlo!iXf1Ti:h,ndSPJlrt, ds, 91-~ots. 

1\5 a barber. Jn the ('.OrnmunJ!:y, ho: U!:ilb:es il l'lfid frllmc D<:nn, fl. B., Walttr, J. s., lucrro1 V,. Weivar, F., l.lmgbllfn. e,. Fttv, L, 

wheelcbnlr. A rrtttnual wheelchair with 11 s.tandl1\g fea.• et al.~l9:9S). flo!l.OW•l.IP .U.'Mfl\\@1'11 of itanding mcb1~devli:<1 u1~f). . . d 1 1 AnfltMi Tirc;h/tQ/ow. 10, 84-93, turc. w11.i prC!$cnl;.od for hun .u~ to severe· comp a nu fhr!li;Ji. 11. J.; .& tanyon. L. E. tzoo2). Mt!ch1111it!ll ~1r11!0 and Qont cell 

of should~t ilnd upper qllaclrant pain 1uid decreased f1,1f\ci!on: A ~lt!w. ~ros& 11mun,<trb1af. 11, 68~-100. 

. , I n d b t:ed h d . Eng, /, J,, lt'MI. s. M., Townion. A. f' Mah·)Ot\llf, o., Brrs1nnar, J., & upi?.ett1Xtren11t:y l':lnct on c U4a yrcp<!-il. over ca kui(oo, G. (?001). 1;1,v.Ql pro!ongcd.nal'ldlnu rm lndlvldu11!J with 

ncdvtlies at homa And work. With thci mll.nua.l wheel~ splnrilcord.!n}u1les.Phy.r{calthtrt1py,.!l1, 1392-1399. 

din.Ir and lts $tanding featUte ht!. W<\.~ nbJe to work f'Or Frltton, S. r.,_Mdsod, K. J" &Rubin, C. 'I'. (t:Oo6), Qu11ntff)fng.ths !V11ln • • J I • • d hlstOI}' o1 bon4! Sputial tWfOl'ltlhy ~I~ ~f·tltnl!Jirlty IJI [OWinawi!luda longer·penod., Qf timfJ RO~ care £or h.is chil ren. 'l'he $Ualni;JourMl(lff1JomKfm./Q1 33, 311-125. 

st:i.ndios; fUAturo allowed Mr. o·. to con1pl0!~ 1\ctiviti<;!;c F1~1~ H. M-. (t9~0). Skera~I s~ctural a:dii1>ta11<w 10 m11chimki1.h1t.'lgt> 

· \n lils fo,:,.,,,, pl•n• Th' led to d sJ• .. ~if:ican~ dueronse. {SATMU)-Rer(.t1~g Wolff's law: TM bone·mix:tellog p1t1b!a1r1. 17iQ 

l\"f a "'' '' ~ ~ Amrofl'!k4/Re«1td1 226, 403"""41.3 

iu cornph1.in.ti of sh.ouldc.r po.irt 11.nd imp.roved upper Goomaor&.: s .•. Van Laott, M., De ·NIM.I, f", & burman, J, M. {1~). 

extren.\Jt-ll'fun Clion, Bonis mineral 51111.11& fn p.11\lpiook 1laVt11ts wflo do.or tJo nt;it pqrlurrn 

1 sU11dr~ Ostr:tJporos/$/nr«tMUo1uJ,.tJ, ta&~t'41. 

HanQartllu, 1. U: {1'9:9!il. onaoporo~s t;hl1f to d'rsuil!. /'liydW Mrdl!ii11~ 

and Reh,J.,/Jirc1.lf"" r:611Ja of North Amfflca,.. 6, 57g...594 ACKNOWLEDGMEN'rS HobSOOi D. A (19.112). Cornpva1N• 41ff~ of p~1Wt on prenure 1t1d 

f!1e11r " tht bcdy'fo~l lllt.offacs. Joum\ll of kMrbl/Jc111fon. /lesearrh 

;indDe~t, ~"<!-), 2'-l1, HQ~niV, H., Murphy, T., Galbtalt11, l.1 & ZotkllW!u, M. (2001). Cat~ U\Jdy 

10 a'lilJU11!& 11: i1andlng ttbl~ <or managing tort$tlpatlon. Spln&J Corr! 

lnjl.Jfy#vrrfrig, 18, 74-71. 

lsrelru17., ~ •• Jr., a11n:.11rd, J. J, Bltkhai1d, ti. c., & Rudahl, K. (1~~), EUe« 

Q1 ptQtonged bed.r11st on urhary aildum oo\p\Jt, Joumal uF App}iur;J 

P/1~. 21, 1013 ... 1020. 

Kaplan, P, E .. U~ru;lhllVndl, 8., RlchirrtJ.s, L, & Goklsi;hmldt; J. (l!J7S). 

Ca.ldum b21anco In p:11apf11glt p11t/on~: !nfh.Jeon'e Of ln]t.lry dunnfo11 

and aJtlb.\.lfail,,n, AtchMI~ of Pll)l$fmf Medkfne a ffeillblHtMfon, SD, 

447.-450. . 

Kaplan,·;, ~. Rodett, W., GUbfrt, I!., JUlh:mts, l., Ill Go!d1chmfdl, J. W~ 

(lga;1). R~1;h,1~!9n Qf hyper~li:Jurla In lt11taolf1)1D afler'M!il}ht bt.lf .. Ing arid Mn9thi<rilnsi Q'll:Ofdses, f'<Jrfμlr.J9/11, t9,.2S9-2~l. 

This •ttklo was dev.eloped tnrough RBSNA'r Spe· 

cinl Interest Group 111 Se•ting nad Wheeled Mobltlty 

(S!G-09) ond npproved by tho R~SNA Bonrd ofDircc· 

~ors. RESNA i!I' :u1 interdisciplinary 11.S.~oclation of 

people wlth·n cpm1non iUt~reJt Jn technology and dis· 

abiHty. R'BSNA ·s purpose· b to improve the potcntinJ 

of pt!apfc: with dis:i.bi!itic$ to nchie"Ya tboJr goals 

through the! usa of technology. RESNA servos that 

purpose by proit1oting research, dev~Iopment1 cductt· 

tion, ndvocacy, nnd· provision of tcchn6ldgy <lnd by. 

s\rpporling tht1 people eng:tged in theso nct:N-lt:ics. · Kvni;et, C. F.1 5somfn1 A.¥ .. l!MribQf9,. s.,.Gatd;i1 J, F., Rob1utt,. s., fl 

MattlMi. S. {1993), f(feGt or ~s~~g" ol] spastldt)I, oontrac;ture, ·· · ··- -· ond ostnopotosls In parafyied tnil~s. A.n;/Jfll~ of P}iyslc;a/ M'!dki~ & R~bilit&f/on, )'4, 73-78. 

Al~<IWI. R.,.tac.os1e, M., 8i Dantetl!.aU, J. (lOOt}. Anidyrls of thdtng and 

prcssura e1~1r1bVtlol\ clvrh\Y u tepodtlonln!J' of pesons In a slinulotor. 

cliri:k-, IEEE Tratis,,ct/CJtJS 1J11 NwN4 $yrtems 11na' 11.EllabfflrorJon rng/. 

nearing, 9, 21S·224. 

Bfmfer, H., J.l<Wm. L. Gtayblfl. c;., Go1ber, N, l., & Welnttob, J. c, 

{1084). Oiteogmesfs lmpei"fada: Rid\alll/lt;iUon approach with 

infants 111\d young: thlldron. Nc11l~'!!J of Phytft.11/ ~kftlt!! 8 R.Mi1bfff. 

flit/on. 6S,.S37-541. 

l}t..iQ:., E. {i. (JSS1). No1,opor11tlvt trt:1irMnt qf o~t1tog11nesi:s. lmpu(ll.d~: 

OrlhoUt. lll'ld l'tlObfflly mam1Qtrot-l'lt. a1111c,,1 Orthop~d/CJ Q; R11latMI 

Remrrh, 1 S9, If 1-122. 

Lan10n, Lr., Si Rulllq; C, T. (IPS4), St11ticVJ dynamic: loads~ ft•I lnflu. 

tntll on bana (•modelUng.Jaurnal.ol /Jfomechan/q, / '1, ·a97-905, 

!Jriyoo, I.. E, 1 fhib!n,.c;:, T,, & ~'\Jft, Q, (19Bb'). Modulatlon of boUC! bu 

dutif!O caldum lnruffld!!nty by i:oritJoHed dyn.untc lo~riinp, Caldffad 

T1n1.1t<lntemarkmal, JB, 209~216, 

luh:, J., Chen, F., & Xaspu, C. {1987). ffy;iokeMdi·!nd\JCCd ne:g11tlv4 

n•t aldtJm balance ttil/l:!flf" by ~eight ~ilrfng e~ortlse. Aviation, 

SpaC!!,, and tnvfronhlr'lntul M!!d/d111>, .SB, 308..J 14. 

M~rtin, A. P .. & Hovston., c. s. (19an. OsraoporOJls, caldum nndphi,islciJI acrMly. Csnad/4n Medlt41 A1t~at1M Joum~. /16, SS7-S$1,}, 

Mardn, A 0,, & MtCutkich, R. (), (1981), Bone lf(,flarn!cs: .Hrim. Sin.Jin 

and fracrurl!>. /(J(Jht11J of Spr::r/it .StftJ11m-t, !i, 155-63, 

67 ------------------ ----------~--- ---·----~-- ----- ----------------------·----·----·· 

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~, .. , 

--~ 

'}' : --_,., - :\"1-

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--··-· __ M:i?l!u, ll. e., &. l/v>hvdon, Cj, D. (19$3). lminobH1211don ahd bone. C;r/ch, ___ Thom~ •. C •. {{., A9onl, S, It,, DWo<'.lfe,· H, ·A .. flfer-MoS!tr.: ·t. M.; ·· fled 11.uue lllterna1(011al, 35, 26S-:tG7. LOO:tturt, T. t., ·& tod:h:it~ t, A. (2000}. Fi;om tfoitr Ii~.&.!: F.1f111;1" of----- -:-----·-- - · ·· 

McK!rll11y, W. o., Jn(~fot't, A. B., Cilrdell<\F, o. 0.1 !Ii D11VJYO, M. I, (1999), dyr.at'1'4:~1ght baar'~ of\ !aJ.l!f ~l!mity b?iie'trJili'~I d,..n.sityl/l·d1R• 

-------tot'1·tom,m«11u_l<ornp11eat1()(\·faftettra·umallc.splnir·C6rt:11oJ\ll'f.·A--~··-·cln11r~th·N!ltu~V'$;\lfar lrl}j:)Ql1mi:f\~..Oipr;;i1J</(l~.dQloaY,.~.4,_.t~::~~-

1eafcm~I rnocM !>)'Stems IU\Jl.lyslt. Arch/yes of Physki/ MKl1"'ne & Trud~ G,, &;lllltfloH, f-4. !<. (2000). Conlf.!ctu-91 soca~ tqJmncliiUtt: 

-------,fleh.&b/Jlt'arlon, 80, '1402-1410. _ 13.IM tintHt.1J9i1 :irtt(l).llr ~- rnygyiari.k> ~pefiment.11L lon<jitt•cltliti Mc~ K. J., 11.tJtilo. c. r .. Ott2r, M. w.. & 011\ Y. ~- (19.86}. Slrnl~AI nvut: in .Ut• rl\ ~. AWi/~$ Pf P/irstcal M':(i/<ltie d Rr:ball!llr11t10n, 

coll .tfreues and bone- idapUitloo, Arnetkan Joumel of tha MM/al 81, S-.UI. . . Sdences.·l1~'17&--o183, irudfii-G;, Uhtl¥iff, H.K., & Sf0\Ht'1 M~C\9Q91. E:il4nl a.hd dl!Gd!onol)uln\ 

Odl!ari,.1.1 a Kr.u1nqn, i. (1~81) •. &v11{uo11on of Iha .eflV-1=1.1 .¢f f!\ll$da trlo~n !Jrp1ta9on fll't~p~b11{1ed tmmalllllty, /(tt"t~xpartmanlal-stUW lrl ~trtl'h Md weliifif Joa.d- ft\ palfmli with sp,.,tf~ plfr.ipl@9I~. Sc.Ytdf. Ult rat, Arcl!Mtio( Pl1W.cil M~ a /f.e/JnAl!il41'°'i, .WJ.- 1~2-1~1. 

· 11~yf.,ti l/JlJri11l CJlReh~f-rtf(on Mf!:!Ji<;Jne, ./3, 4 11.;.1~11 Ward, K.; ~, c., c,l.11~1\ .1'< Rlh)r, .c., ~d.:ifl'f, f. 1 ~Mo.191'ial, Z. (.!QM), 

llulilfl, c;, T., 8c t.an}'Of\ L. !. 0984). Rn<i"tJIAtkm cf bOJli form~\lon by WN tr1a~n!Wde Q1edmnkitl loadlng·u .ouaogark In d;i\!doo .whh cfls- 11pp~d dyn~m1¢ loads. Jqvtml of Bonot l'l lo/nt Sumco-Amwkan allllng: c:ohdldtin!. Jo<Jmll/oloone uid lvth~-Rereari;h. )p,.ge0.:.3"Q9, 

VukJ~, 66, 307.:...W2. Wh"dan, G. D~ '19al), Ch11fl.Q•• kt w.:il9t\th1ssoes.s VJ ~ci\lw meill!»- S!m~!n. A,,.~ Ay~Jon, J. (19!;10). S!)lleof~drnu; 11J4 new way to ,o1ew11r . Hs1n arid II'\ 11'1' !'t'ltli¢tihsk'!l&"tal wsiem. ·Ph~~i. 2~;.'$41-:-S44 .. ~tld 0:1i11bti-t tht! rhlrinfn~ bono.r ct a.rteoporo;tl.S, tondcn· Prfan. v...'h«fon. G, o. {1911$). lM lnO'~nte- ot q_c;""'ty on (.1kT1;KJ1111etabol!sm. 

S111nkl, M, {'J'J9S}. Mt,1~!9d:~te_tp.f rehabOflaUon. II\ S~ l. l\lggs & /¢;Ufna:I of M.rtrftlor..tl Science d VlrMnl{lofogy.-31{~pl.),·$4.1-S4'1, 

L. J, Ma/tM m {F.c/1.}, OsrfldpotMl.r: Er/ol.o{lA dla911()!1.r, /Jlld f11l'hD$f- \Nlwdon, G. o., t.vM'.:i~. ~. R.rntiaui., r., Whitt!•, M .. t.ei!Ch, c,1 l\itt9,.J .. 1n:w(p]l.. d35-4'1J), Phl\aclelpf\!~: l.iop+ncott·!laytl\. 1Jl Ill (1975}. Minero!_ and 1~\fCJ9(!JJ mMil®lk: ~l1.1tllcn;·o11 Sk.ylab 

S1n!ns&y, K .. Si lhornton. H, (I 999, 5).lrlog}. Jl.frtl"1fng th&· i:iTOIArlon of 1 H19hlt 11rid (omPorttan with 'ffettt cf e-~rth fQnst·-l~rm trr.um\;leric.y, 

slltndltfra (ram~ for hOfl"l': usu-A!Jaod use to quole. S}mpSf,pp.!-S LJ/i1SdUlc4d $~Reseb1'Cll, Ji(, 1 \$-\a7. 

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·-···--~--·--·-·-------~-----------------·-·-·------------- ·----------·-·---- .. ------------------·-----"-·------------·· 

000087 
TAB 5
Aug 27 13 04:37p Amy Morgan 859(.j:J877 

.• p.1 

AFFJDA YIT OF AMY MORGAN, PT, ATP 

STATEOFKENTUCKY § 

COUNTY OF BOONE § 

BEFORE ME. the WJdersigned authority, -0n rlJis day perS-Onally appeared Amy Morgan, 

who being first duly sworn, states the following: 

I. My name is Amy Morgan and the facts to which I attest herein are from my personal 

knowledge and I am competent to testify as to same. 

2. The following statements are based upon my experience in the field of physical 

therapy and· rehabilitation technology. I am a Licensed and Certified Physical 

Therapist and a certified Assistive Technology Professional (ATP). 

3. I am employed by Permobil, Inc., a manufacturer of complex rehabilitation power 

wheelchairs for over 45 years. I am the National Clinical Education Manager and 

Standing Specialist with Pennobil and am responsible for provicling education and 

training in regards to power mobility lUld assistive technology, providing clinical 

feedback to the design team for product features, and assisting lhe rehab team with a 

clinical decision making framework to ensure the most appropriate and cost-effective 

option is being recommended. (Resume, Attachment A) 

4. I am very familiar with the Pennobil CSOO VS wheelchair which enables the user to 

ind~pendently stand at any tjme and m any location. This wheelchair is unique 

because the multi-positioning power standing system allows. the user's body to be 

extended before gravity and weight-bearing begin. This is extremely important for 

users as it allows a customized standing sequence, which will accommodate for any 

postural control or orthosra1ic hypotension issues as well as ensure appropriate 

postural alignment and reduce the risk of shearing and sliding which can compromise 

skin integrity. 

5. The multi-positional standing system (E2301) of the CS 00 VS must include the 

following power seat functions for the mechanical operation of this wheelchair: 

(a) Tilt and recline (E 1007) 

(b) Center mount articulating elevating legrests (KO 108) 

(c) Stand and drive legrest assembly (KOlO&) 

(d) Seat elevation (E2300) 

The tilt/recline and elevating legrests allow the user to fully extend their body in 

preparation for standing. The stand and drive legrest assembly provides the anterior 

stability required for safety and balance of the chair while standing, and also allows 

the chair to move in the standing position. The adjustable seat height ensures stability 

of the chair by allowing the stand and drive caster whee ls to be appropriately in 

·------- ··--------------~---------------,------··-----------~·-· -·-~--·--- .... - ... ·----····-·· ·--------~---------·--

------------.i1r->t'l-r:::5--,--------,-pr_n15:r-------

000293 
Aug 2713 04:38p Amy Morgan ) p.2 

contact with the grounel - creating this anterior stability for safety. The Permobil 

C500 VS cannot be ordered without the power seat fimctions. listed above and must 

also include the multiple seat function control kit as it utilizes multiple power seat 

functions. (E2311) 

6. The medical benefits of standing for individuals with spinal cord injuries is well 

·documented. In 2009, the Rehabilitation Society of North America (RESNA) 

published a peer-reviewed article entitled RESNA Position on the Application of 

W11eelchair Standing Devices, Assistive Technology 21 :3,161-168 (Attachment B) 

7. Ibis article reviews the scientific and clinical evidence regarding the medical, 

functional, and psychosocial benefits of wheelchair standing devices and concludes 

that this type of wheelchair is medically necessruy for certain individuals to maintain 

vital organ capacity, improve circulation and passive range of motion, reduce the 

occurrence of urinary tract infections, avoid Joss of bone mineral density, decrease 

abnormal muscle tone and spasticity, prevent the occurrence of skeletal deformities 

and reduce the occurrence of pressure sores. 

8. As noted in this report, "standing is an effective way to counterbalance many of tbe 

negative effects of constant sitting" The medical benefits of standing areachieved 

by; 

• Allowing the wheelchair user to extend' his or her hip and knee join1s in order to 

decrease the development of contractures in the lower extremities; 

• Providing better alignment of the spine and extension of the upper trunk, resulting 

in reduced pressure on the wheelchair user's internal orgatls, and avoiding the 

onset of respiratory c.,-mnplications often experienced by prolonged sitting in a 

wheelchair. 

• Allowing a wheelchair user to more completely empty his or her bladder, thus 

decreasing the onset of hypercalcemia and urinary tract and kidney infections. 

• Reducing the occurrence of chronic constipation, which can lead to bowel 

obstruction. 

• Addressing the loss of bone mineral density, which causes osteoporosis and an 

increased risk of :fractures. 

• Improving blood circulation in the lower extremities and reducing swelling in the 

lower extremities. 

• Aiding In the reduction of excess muscle tone and muscle sprurucity to reduce 

pain, improve comfort and function, and minimize loss in range of motion . 

.. ---------- -----------~~-·---------·---

----------..i-1 -15~--------,.p .... _~15~-·-·----.. 

000294 
l\ug 2713 04:38p Amy Morgan ) 85!'":}60877 p.3 

\ 

I 

.; ~__...~ 

• Providing complete pressure relief on the isclrial tuberosities, which can decrease 

the occurrence of pressure ulcers. 

9. A wheelchair with integrated stander enables the user to independently move from a 

silting position to standing through gradual angle changes and allows him or her to 

obtain full upright or partially tilted positions to address the many adverse secondary 

medical complications that result from prolonged sitting. 

10. The standing feature of the Permobil C500 can be used while the wheelchair ig 

stationary or while moving at low speeds. It provides numerous opportunities for 

dynamic loading of the lower extremities and is more effective in reducing the risk of 

loss of bone mineral density (BMD) as well as promoting improvement in BlvID. As 

stated in the RESN A report, "integrated standers allow for standing nearly any time 

for any length of time, and therefore weight loading is more likely to be of random 

distribution, which appears to be superior in BMD loss prevention." 

11. Separate standers do not provide dynamic loading and are less effective in reducing 

· the risk of bone loss than wheelchairs with integrated standing features. For some 

.individuals, use of a separate stander requires one or more caregivers to assist with 

transferring the individual into the standing device. As a result, the wheelchair user's 

ability to stand is limited by the availability of assistance to transfer him or her into 

the equipment. In contrast, independent standing from one's own wheelchair 

decreases dependency on others, minimizes the risk of transfer injuries, and increases 

the opportunities for standing in multiple locations throughout the day, which has 

been shown to be more dfective for physiological function ( ei.:. BMD, 

Bowel/Bladder function/Gastrointestinal motility, Range of Motion/Spasticity 

management/Cardio-Respiratory function/etc.) 

SUBSCRIBED AND SWORN TO before me, the lUldersigned authority, on the 8-"1 day 

of August, 2013. 

000295 

.JESSICA LUCAS 

Notary Public, Kentucey 

State At Large 

My commission EXpires 

February 13, io1E> 

Nolaf'/ IDff 460283 

,--. 

~()~ <§,' 6 1-J'/l. Q 

NPublic 

17 P-16 
TAB 6
LlSA R. WENZEL, M.D. 

Auistant Pro!c:uor 

SplneJ Cord. llljury Proif&lll 

Physic:a.J MedlcitJc A Rehabilitation 

Date: September 26, 2013 

Pt: Linda Puglisi 

DOB: ?5!??"221 

To Whom It May Concern: 

) 

/ 

BCM 

B;iylor O:illegcGf.Mc:d!cioe 

LETTER OF MEDICAL NECESSITY 

My name Ls Dr. Lisa Wenzel I am an assistant professor of Physical Medicine .and 

Rehabilitation at Baylor College of Medicine and a splna! cord injury jlttending at TIRR 

Memorial Hermann Hospital I am also a member of the American Academy of Physical 

Medicine and Rehabilitation and the American Spinal Cord Injury Association. 

In my position at TIRR Memorial Hermann Hospital, I am responsible for both the inpatient and 

outpatient care of individuals with spinal cord injuries, including management of such conditions 

as neurogenic bowel and bladder, pressure ulcera, spasticity, and neuropathic pain. 

Ia. February 2013, I was the attending physician for Linda at TIRR Memorial Hermann Hospital 

During thi.s inpatient stay, Linda underwent a comprehensive evaluation for a power wheelchair. 

As a res:ult of this evaluation, we recommended a custom power wheelchair with an integrated 

standing feature for Linda. l provided the required attestation of medical necessity of the 

recommended power wheelchair on a form provided by Texas Medicaid. 

I also provided additional medical support for the recommended wheelchair on May 9, 2013, in 

an earlier Letter of Medical Necessity. This letter explains the numerous secondary medical 

conditions Linda's faces due to her spinal cord injury and how these medical conditions can be 

managed by frequent independent standing throughout the day. The letter also explains that a 

separate stander is not equally effective in addressing these medical conditions and will not 

provide the same medical benefits for Linda. 

P-13 

;--~· -···-·--: ... ---·----·--------------------·----··· .. ---~- -- ------

000287 
LISA R. WENZEL, M.D. 

Assist:ant Pmfes~or 

Spiaat Cord Injury Program 

Phy~ical l\.fedicine & Rd1abilituion 

BCM 

:SayJor College o/Medicint; 

The team responsible for conducting Linda's wheelchair evaluation in February 2013 'continues 

to support their recommendation for a custom power wheelchair with integrated standing feature 

for Linda. The Pennobil C500 VS is recommended to address Linda's medical needs and is not 

recommended for her convenience or the convenience of her caregivers. 

Sincerely, 

LisaR. Wenzel,MD 

Attending PhysiCian 

Physical Medicine and Rehabilitation 

Spinal Cord Jn jury Program 

TIRR/Memorial Hermann Hospital 

Baylor College of Medicine 

000288 
TAB 7
S'l'A'l'E OF NEW YORK 

.DEPJIR'l'MEN'l' OF SOCIAL SERVICES 

In the Matter of the Appeal of 

Mary k 

from a determination by the Office of Health 

RBQUBST UULy ~~, •~~~ 

PRIOR APPRO~ # none 

CME# BJ7\l;i:ass 

CEN'l'ER# OHSlf 

FH# 185S$18J 

Dl!CISION 

Ali'\l'ER 

FA~R 

HEARING 

Systems Management of the New York State Department of 

Health (hereinafter referred to as the Agency or OHSM) 

JURISDICTION 

Pursuant to Section 22 of the New York State Social Services Law 

(hereinafter Social Services Law) and P;zrl: 358 of the Regulations of i:he New 

York State Department of Social Services (Title lS NYCRR, hereinafter 

Regulations), a fair hearing was held on September 16, 1992, in Dutchess 

County, before Lewis J. Nestle, ·Administrative Law Judge. The following 

persons appeared at the hearing: 

For the Appellant 

Andrew Alter and Barbara Nectow (Mid-Hudson Legal Services), Appellant's 

Representative 

For the Office of Health Systems Management 

Submitted, personal appearance waived. 

Was the Agency's determination not to process the Appellant's vendor, 

Daves Wheelchair, Inc.•s prior approval request correct? 

FACT FINDING 

An opportunity to be heard having been afforded to all interested 

parties.and evidence having been taken and due deliberation having been had, 

it is hereby found that: 

1. The Appellant has been in receipt of a Medical Assistance 

authorization. The Appellant.is also eligible for Medicare benefits. 

2. On June 25, 1992, the Appellant's vendor, Daves Wheelchair, Inc. 

requested prior approval for an Avant wheeled walker for the Appellant. 

3. On June 26, 1992, the Agency determined to return the Appellant's 

vendor, Daves Wheelchair, Inc.'s prior approval request on the grounds that 

the vendor must bill Medicare first. 

' 

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FH# 1858S18J 

4. On July 24, 1992, the Appellant requested this fair hearing. 

APPLICABLE +.AW 

Section 3.65-a of the Social Services Law provides in part: 

2. "Medical Assistance" shall mean pal'lllent of part or all of th•f · 

cost of medically necessary medical, dental and remedial care, 

services and supplies, as authorized by this title or the 

regulations of the department, which are necessary to prevent, 

diagnose, correct or cure conditions in the person that cause 

acute suffering, endanger life, result in illness or infi:rmity, 

interfere with such person's capacity for normal activity, or 

threaten some significant handicap and which are furnished an 

eligible person in accordance with this title and the regulations 

of the department. 

Section 364.2 of the Social Services Law provides in part, as follows: 

The department of health shall be responsible for 

{b) establishing and maintaining standards for all non-institutional 

health care and services rendered pursuant to this title, 

* * * 

Section 2.1.4 of the New York State Medicaid Management Information 

System {]@ilS) Durable Medical Equipment Provider Manual defines prior 

approval as the process of evaluating the aspects of a plan of care which 

may be for a single service or an ongoing series of services in order to 

determine the medical necessity and appropriateness of the care requested. 

Section 2.2.2.B. of the MMIS Durable Medical Equipment Provider Manual 

and, effective February 20, 1991, Department Regulations at 18 NYCRR 

sos .s {a} (l.} define "Durable Medical Equipment" as: 

devices and equipment, other than prosthetic or orthotic appliances, 

which have been ordered by a qualified practitioner in the treatment of 

a specific medical condition and which have all of the.following 

characteristics: 

Can withstand repeated use for a pr0tracted period of 

time1 

Are primarily and customarily used for medical purposes; 

Are generally not useful to a person in the absence of an 

illness or injury; and 

Are usually not fitted, designed or fashioned for a 

particular individual's use. 

Where equipment is intended for use by only one patient, 

it may be either custom made, or customized. 

-------------------------·--
3 

FH# lSSSSlSJ 

"Custom-made" means fabricated soJ.ely for a particular individual and 

cannot be readily changed to conform to another recipient's needs. It 

usually requires the recipient to be measured for custom fitting and/or 

molding of components. 

"Customized" refers to a stock item that has modifications made and/or 

attached (to it} to meet a recipient's needs. These modifications may be 

changed (by adding or deleting items such as armrests, etc.} to return the· 

item to stock. 

Section 360-7.2 of the Department's Regulations provides: 

Where a third party, such as a health insurer or responsible 

person, has a legal liability to pay for MA-covered services on 

·behalf of a recipient, the department or social servlces district 

will pay only the amount by which the MA reimbursement rate for 

the services exceeds the amount of the third party liability. 

The department or social services district will also pay if the 

third party payment will not be made within a reasonable time. 

The department or social services district will seek 

reimbursement for any payments for care and services it makes for 

which a third party is legally responsible. They will seek 

re~rnbursement to the extent of the third party's legal liability 

unless the amount reasonably expected to be recovered is less 

than the cost of making the recovery. 

Section 360·7.3 of the Department's 

health, hospital or accident insurance. 

hospital or accident insurance benefits 

his/her medical needs. 

Regulations provides for the use of 

A recipient must use health, 

to the fullest extent in meeting 

Section 2.2.l2f of the .MMIS Provider Manual states, in part: 

DISCUSSION 

When a procedure requires prior approval, prior approval must be 

obtained by the provider when a recipient has both Medicare and 

Medicaid coverage in order to receive Medicaid payment for 

Medicare deductibles and coinsurances except when the request 

involves rentals •.• 

It should initially be noted that the Agency had requested a waiver of 

personal appearance which was opposed by the Appellant's counsel. The 

material in support of the request and in opposition to the request was 

carefully reviewed and it was determined that the waiver would be granted 

because of the absence of any factual issues. The matter was discussed at 

the hearing and the Appellant's Representative elected to proceed with the 

hearing in the absence of the Agency. · 

I 

i 

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FH#'lBSBSlSJ 

The Appellant receives both Medicare and Medical Assistance benefits. 

The Agency, in its submission, contended that the Appellant was required to 

explore Medicare approval first because the Medical Assistance Program is 

the payor of last resort. 

The.Agency's contention is not persuasive. The issue here is a request 

for prior approval, not a request for payment. Although the Medical 

Assistance Program is the payor of last resort, the question of payment is 

not relevant to the issue of prior· approval. Section 2.1.7 of the Manual 

states that payment will not be made for medical care and services for which 

third parties e.g., Medicare are liable. Similarly, Section 2.1.9 of the 

Manual speaks to the provider·' s responsibility to bill all applicable 

insurance sources before submitted a claim for payment under the Medical 

Assistance Program. However, the Appellant is entitled to have the Agency 

determine whether the walker is medically necessary which is a separate and 

distinct question from the amount of Medical Assistance payment, if any. 

Under these circumstances, the Agency will be required to process the 

Appellant's request for prior approval and determine the medical necessity 

of the walker. 

The Appellant's Representatives requested that the question of medical 

necessity be resolved at this hearing and submitted a copy of a letter dated 

June 15, 1992 from the Ms Comprehensive Care Center in support of the 

request. This request is denied. The Agency sununary indicated that the 

Agency had granted prior approval to make repairs to the Appellant's 

wheelehair. As set forth in the cited legal authority, it is the Agency's 

responsibility to determine medical necessity for the·purchase of durable 

medical equipment. Under these circumstances, the appropriate remedy when 

there has been an improper failure to act or when the Agency has returned a 

prior approval request for an improper reason, is.to require the Agency to 

process the request and to make a determination. 

The Appellant's Representatives further contended that the rate of 

reimbursement set forth in the MMIS Provider Manual in this type of 

situation is contrary to federal law. The Manual provides that 

reimbursement is the lesser of the difference between what Medicare pays and 

·the Medicare approved amount (the co-pay) or what Medica~e pays and the 

Medical Assistance rate. The Appellant's Representative contended that this 

limitation violates federal Title XIX requirements regarding amount, scope 

and duration of benefits and that a similar policy had.been enjoined in 

California. However, inasmuch as no determination has been made as to prior 

approval of the walker, it would be premature to address the question as to 

the amount of payment in this decision. 

DECISION AND ORDER 

The determination of the Agency not to process the Appellant's vendor, 

Daves Wheelchair, Inc.•s prior approval request is not correct and is 

reversed. l 

~ 

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FH# l858518J 

The Agency is directed 

.medically necessary and to 

its determination. 

s 

to detem~~Ef:\Yh,'i,the~ t~? ~y~t wh~el walk<t,r ··

0

11o,:fs ... • ... advise the.~~pe;Hant. a,.;id·her .ll.ePresentati:ve - ' '' ; ~- -: . ·- ·- .. • .. --,.: . . -· . -

. .: -' '.·- .. ~ -

. As i;equired by Department !iegu~atio>;ls ~t i.a ?n'CR.R asa-6 .. 4, the AgenGr ' · 

must comply immediately with the d.ire.ctiirl!s set :f¢r~h ¥P\'El· ·. 

DATED: Albany, New York 

ocr o I 1992 NEW YORK STATE DEPARTMENT 

OF SOCIAL SERVICES 

By 

~ Commissioner's ~.~ Designee 

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TAB 8
HHSC Fair and Fraud Hearings Handbook 

(Excerpt) 

1565 Agency Action Notice Issues 

Revision 11-4; Effective June 1, 2011 

Whenever an adverse action is taken, programs are required to send an adequate notice to the 

client. Federal law sets out what is to be included in adverse action notices. If the appellant raises 

an issue at the hearing questioning the sufficiency of the notice, the hearings officer must address 

the issue at that time. The hearings officer may direct the agency to send a con-ected notice, in 

accordance with all legal requirements. The appellant may choose to waive any notice issues and 

continue with the hearing. 

Notices are of particular impo1tance in nursing facility discharge hearings and in Personal Care 

Service hearings and adequacy of the notices must be addressed as an issue within the hearing in 

addition to other issues listed as the basis for the intended adverse action. In these appeals, if the 

notice issue is not raised by the appellant, the hearings officer must develop the record to include 

information to determine the legal adequacy of the notice. 

1565.1 When Appellant Raises a Notice Issue 

Revision 10-1; Effective January 15, 2010 

If the appellant raises a notice issue, either directly or indirectly, it must be dealt with by the 

hearings officer on the record. The appellant has the right to receive adequate notice. However, 

the appellant can waive any notice issues and continue with the hearing. It is the hearings 

officer's responsibility to establish if the appellant wants to waive any issues on adequate notice. 

If the appellant waives any notice issue, then the hearing can proceed and notice is no longer an 

issue. 

If the hearings officer determines that the notice is not adequate and appellant does not waive his 

right to receive adequate notice, the hearings officer instructs the agency representative to 

prepare a new notice and provide it to the appellant. After the new notice is provided, the 

hearings officer reconvenes the hearing. 

Notice issues raised and how they were resolved should be noted in the hearings officer's 

decision under Procedural History.