Quadriplegia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. In older patients with spinal cord injury, long-term medical complications can result in reduced community participation and quality of life as well as frequent hospitalizations. Some studies have reported that FES interventions with hand and leg cycling systems can be effective in helping to prevent secondary health conditions in patients with incomplete injuries, improve conditioning and fitness levels of patients, and increase patients’ participation in the community.

The enrollee requested coverage for water physical therapy. The patient is diagnosed with Guillain-Barre syndrome, quadriplegia, and multi-joint osteoarthritis. Analgesic medication and aquatic therapy has helped in the past. Guillain-Barre syndrome affects one to two people per 100,000 people in our population each year. Disability caused by Guillain-Barre syndrome generally progresses over the course of a day to weeks. Various physical therapy regiments, including water physical therapy, can help the active movement of muscle groups that are not yet able to move independently against gravity. These activities may facilitate stretching, strengthening and pain relief. Water physical therapy has been shown in literature to improve conditions such as joint osteoarthritis similar to, if not more than, land physical therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested accessories for the power wheelchair, a Standing Seat (E2301) and the Power Seat Elevation System (E2300) for treatment of the enrollee’s quadriplegia. The physician reviewer found that power standing is not of proven benefit with respect to health or functional outcomes in the setting of neurological or neuromuscular conditions resulting in standing or ambulatory dysfunction. Currently, there is a lack of high-grade evidence to support that this type of feature improves pulmonary function, circulation, bowel or bladder function, improves muscle function, skin integrity, bony health, or provides other health benefits in patients who are otherwise generally poorly mobile using their own body power.

A 21-year-old female enrollee has requested a power wheelchair for treatment of her quadriplegia. Findings: The physician reviewer found that there is no indication in the records that the patient’s medical and functional needs support the medical necessity of a power mobility device. There are no documented impairments or postural issues that establish that her seating needs would be better addressed with a seating system on a power mobility device. Tilt-in-space and full recline functions can be provided on a manual wheelchair. Having attendant-controlled powered tilt-in-space and recline is for caregiver convenience but is not considered medically necessary. The patient’s ability to tolerate upright sitting would not be expected to be significantly improved with a power mobility device than a manual wheelchair.

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 quadriplegia, then check the rights and deadlines that apply to your plan.