Power Scooter denials in California external review

What the reviewers wrote

Where the denial was overturned

A 53-year-old female enrollee has requested a power scooter for treatment her back and left leg pain. Findings: The physician reviewer found that the requested equipment is medically necessary for treatment of the patient’s medical condition. The medical literature supports the requested equipment in this clinical setting. According to Edwards and colleagues, “Power wheelchairs and scooters have the potential to increase community participation for people with mobility limitations.” The authors investigated the characteristics of adults who use power wheelchairs and scooters, the process of power-mobility provision and the benefits and challenges of use.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power scooter for treatment of the enrollee, who is a T5 paraplegic. Findings: The physician reviewer found that power mobility can benefit specific individuals. This patient reported that he would like a power scooter to improve community mobility and lessen the physical demands of manual wheelchair usage which may be impacting his overall wellbeing. This patient has a personal mobility deficit and has safely used a power scooter in the past which improved his level of independent function. A power scooter is medically necessary to achieve the primary goal of spinal cord injury rehabilitation, maximizing the patient’s independence. Thus, in this patient’s case, the requested power scooter is medically necessary for treatment of this patient.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the use of a power scooter. The records indicate that this patient has a history of multiple myeloma and degenerative disc disease. The patient initially underwent a mobility evaluation. At that time, the patient was able to ambulate in their home and in the community with the assistance of a cane or walker. The provider’s letter indicates that the patient was diagnosed with multiple myeloma and has experienced a decline in their ability to ambulate and perform daily activities. They are reported to experience increased falls. The patient has requested the use of a power scooter due to a decline in their level of mobility and function.

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