Paraplegia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wheelchair accessories [two-sided ABS footrest cover; titanium frame; push handles; Spinergy LX performance wheels; natural fit hand rims; side guards; scissor lock brakes; and/or custom fabricated seat cushion] for the authorized ultra-lightweight manual wheelchair with Smart Drive power assist. This patient presents with a medical history of T6 paraplegia since 1992. The records document that the patient has been experiencing bilateral arm pain and she has a neurogenic bladder. The patient’s provider has recommended a new manual wheelchair. A physical therapy assessment performed on 6/25/23 indicated that the patient’s current wheelchair is old, too small, and falling apart.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Percocet 10 mg tablets, two tablets, three times per day, and (2) Norco, 10 mg tablets, one tablet, five times per day. On determining when to initiate or continue opioids for chronic pain, researchers report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the use of a power standing feature for the already approved powered wheelchair. The records indicate that this patient presents with complex intractable epilepsy, developmental delay, cellulitis, neuropathy, mild ataxia, and paraplegia with hypotonia. The patient has been noted to currently require a manual wheelchair for mobility that a caregiver must propel. The medical records lack sufficient documentation regarding the patient’s current level of function in terms of performing daily activities and mobility, as well as physical examination findings, including graded motor strength and range of motion of the upper and lower extremities.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an exoskeleton device. Current medical literature does not support the use of powered exoskeletal ambulatory assistance devices as an efficient, reliable or practical means of mobility for persons with paraparesis/paraplegia or other neurological disorders impairing upright ambulation. Researchers found that the applicability and effectiveness of lower limb exoskeletons as assistive devices in the community have not been demonstrated. Additionally, researchers note that the weight of exoskeleton devices, the need for upper extremity supports, supervision requirements, and a limited range of movements are issues that restrict opportunities for using such devices in real-world contexts. Medical literature shows that the use of exoskeletons comes with considerable feasibility challenges.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving paraplegia, then check the rights and deadlines that apply to your plan.