Electric Scooter denials in California external review

What the reviewers wrote

Where the denial was overturned

A 57-year-old male enrollee has requested a mobility scooter for treatment of his degenerative joint disease and osteoarthritis. Findings: The physician reviewer found that this patient has significant mobility impairments that cannot be successfully resolved by crutches, walker, or a manual wheelchair. He is unable to use these devices on a consistent basis due to inflammatory changes in his hands due to rheumatoid arthritis, confirmed on physical examination and x-rays. Notably, he also has ulnar deviations and has been started on Plaquenil, a disease modifying agent, to mitigate development of joint deformities. Relative avoidance of activities that would continue to inflame the involved joints would be appropriate. Overall, the patient is unable to successfully resolve his mobility impairments through self-powered means such as crutches, a walker or a manual wheelchair.

The patient is a 57-year-old male with an acoustic neuroma, apparently post-neurosurgery, with significant residual neurological deficits. The patient requires mechanical devices in order to function. The patient experiences frequent falls. He was seen and treated by a neuro-otologist in 2003 and 2004. In addition, it appears the patient has left-sided deafness, impaired vision, and substantial loss of coordination. He has obtained a POV and lift and has requested reimbursement for the equipment at issue. In many cases patients with an acoustic neuroma experience severe neurological deficits and require major rehabilitation and mechanical aides. Based upon the records provided, the patient is severely handicapped and cannot functionally ambulate or safely and effectively operate a manual wheelchair. He requires mechanical aides that are necessary for his ability to function.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for an electric scooter. The enrollee has worsening pain in both feet. A progress note includes diagnoses of corns and callouses, and pain to bilateral feet and ankles. The patient was evaluated by her treating physician. Medical records show the patient had bilateral bunions, with thick tender callusing of both feet. However, there were no focal deficits. The upper and lower extremity motor and sensory examinations were described as normal and intact; respectively. The patient was assessed for an electric scooter by a physical therapist. The therapist reported the patient is fully ambulatory, without the use of a device, such as a cane, and was not restricted from driving a motor vehicle.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the electric scooter. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee’s chronic low back pain. Findings: The documentation provided does not support the medical necessity for the requested equipment in this clinical setting. The records indicated a musculoskeletal examination that was within normal limits. The patient’s COPD is managed with bronchodilators, steroids and supplemental oxygen as needed. However, the records do not indicate that the patient has neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using assistive devices or an optimally configured manual wheelchair to accomplish her mobility related activities of daily living.

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