Electric Wheelchair denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested durable medical equipment in the form of an electric wheelchair for her musculoskeletal condition. Findings: The physician reviewer found that she has not been able to effectively and functionally propel herself for a number of years. She is dependent upon caregivers to help her navigate her surroundings via her manual chair. The patient is not able to propel herself in her wheelchair as her body structure, impaired upper body strength, and the supporting surfaces on her wheelchair make it difficult. With her current wheelchair, she is not able to perform certain activities of daily living. Further, her social interactions have been negatively impacted by her difficulties with functional mobility. The current medical evidence supports the requested equipment in this clinical setting.

The parent of an 18-year-old female enrollee requested authorization and coverage of an electric wheelchair for the treatment of cerebral palsy and spastic diplegia. The health plan denied the enrollee’s request indicating that an electric wheelchair is not medically necessary. The Plan authorized a self propelled lightweight wheelchair.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plan’s denial on the basis that the requested equipment is medically necessary.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for an electric wheelchair and an extra wide, firm, electric hospital bed. A review of the provided documentation reveals that the requested services are not medically necessary for the patient. Reliance on motorized mobility, when ambulation or manual wheelchair use is feasible, can have detrimental effects on cardiovascular health and expected longevity. In this case, the record indicates that the patient has no documented impairments in strength, sensation, range of motion, or coordination with respect to the upper limbs. Patients with chronic health conditions generally benefit from exercise such as that afforded by walking or self-propelling a manual wheelchair.

Nature of Statutory Criteria/Case Summary: The patient presented for a physical therapy evaluation on 7/29/18. The records indicated difficulty with ambulation due to pain and fatigue. The patient ambulates short distances inside the home using a four-wheeled walker with a seat. She lives with relatives in a wheelchair-accessible single level home, and does not spend time alone in the home. The records noted that she has a group 2 power wheelchair in good mechanical condition, which she uses intermittently in the home and to access an outdoor mailbox. She has adequate support to assist with shopping and transportation to medical appointments. On examination, the patient was noted to be obese with active range of motion in the upper and lower extremities within functional limits. She is independent for transfers and toileting.

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