Power-operated Vehicle denials in California external review
In the California DMHC record, independent physician reviewers decided 51 published external-review cases involving Power-operated Vehicleand overturned the plan’s denial in 2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Power-operated Vehicle denials
| Category | Decisions | Overturned |
|---|---|---|
| Rheumatoid Arthritis | 4 | 0% |
| Morbid Obesity | 3 | 0% |
| Multiple Sclerosis | 3 | 0% |
| Osteoarthritis | 3 | 0% |
What the reviewers wrote
Where the denial was overturned
A forty-four year-old female with primary progressive multiple sclerosis is requesting reimbursement for a power operated vehicle and related accessories. Reviewer’s Findings: The reviewing physician found that the submitted clinical records indicate the patient has an impaired ability to ambulate and is unable to push herself up independently from a chair. The reviewing physician found that the Health Plan denial should overturned.
Where the denial was upheld
The patient is a female diagnosed with asthma, type 2 diabetes, fibromyalgia, hallux valgus with bunions, and chronic low back pain with bilateral sciatica. The patient reported that she was unable to walk to a bus stop and was unable to sit on a bus for prolonged periods of time due to back pain. The patient underwent a functional mobility assessment. The patient was able to ambulate in her home without the use of a walker. She has a history of using a four-wheeled walker with a seat for ambulating longer distances in the community. The patient’s home was not wheelchair accessible. The patient’s upper and lower extremity strength was noted to be within functional limits. Her sitting and standing balance was intact. There was no history of falls. The patient has requested coverage for a power operated vehicle (motorized scooter).
The patient is a 49-year-old female with a history of type 1 diabetes mellitus, bilateral carpal tunnel syndrome, goiterous thyroid, sleep apnea, hypertension, morbid obesity, degenerative disc disease and bilateral lower extremity weakness. Her need for a power operated vehicle (POV) was assessed in May 2006 by a physical medicine and rehabilitation (PM&R) and pain specialist; at that time she was able to propel a manual wheelchair. The patient indicates she is in need of various types of adaptive equipment. She has requested authorization for a POV, hospital bed, lift chair, access ramp and automobile wheelchair lift. Her request was denied by the Health Plan based upon a determination that the requested equipment is not medically necessary.A neurological examination in February 2006 documented normal strength in the upper extremities.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Power-operated Vehicle, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY