Power 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 a power wheelchair with specifications noted, for treatment of her spinal muscular atrophy. The physician reviewer found that the submitted documentation supports the medical necessity of the requested power wheelchair with each of the requested specifications. Spinal muscular atrophy is a disease without a cure that requires accommodation of functional impairments for treatment. This patient has significant impairments and requires a power wheelchair to remain independent. She requires each of the requested components for various reasons. Power tilt and power recline are needed for pressure relief and repositioning. Power seat height and anterior tilt are needed for independence with transfers.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a power wheelchair/power gurney for treatment of his multiple osseous deformities and severe scoliosis. Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the requested power wheelchair. According to the medical literature, “The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem.” Power mobility can benefit specific individuals. The determination of who will benefit is a matter of clinical judgement more than of adherence to criteria defined by the literature. In this case, the patient has profound deficits of functional mobility for which he depends on the modified power wheelchair that has been requested. He has been using a power wheelchair for most of his life.

Where the denial was upheld

The patient has a history of diabetes mellitus, end stage renal disease (on hemodialysis), neuropathy, a toe amputation, and reported blindness. The patient was assessed by a physical therapist in his home, who noted that the patient is `totally blind.` It was noted that the patient lives in an apartment that has nine steps for ingress/egress. He was noted to require minimal assistance for performing activities of daily living due to his inability to see. The patient reported falls, the last of which occurred one month prior outside the home when he was using a cane. The patient was observed during the encounter to perform sit to stand transfers and to walk 15 feet twice, independently. He was noted to not leave his home without accompaniment. The patient had transportation available for his hemodialysis appointments three times per week, as well as for his medical appointments.

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 wheelchair to perform one or more mobility-related activities of daily living (MRADLs) or instrumental activities of daily living in or out of the home, including access to the community. The medical literature provides specific criteria for the use of power wheelchairs. The indications for a power wheelchair include the following: 1) “the user must meet the general indications for motorized mobility; 2) demonstrated need for a powered device for functional mobility within the home or work environment; 3) postural support needs that cannot be met with a scooter or significant time to be spent in the power wheelchair; 4) requires power tilt and/or power recline mechanisms to promote skin integrity or to manage medical conditions…

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