Special Bed denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a safety enclosure canopy for use with a cubby safety bed. As noted in the medical literature, hospital and customized hospital beds may be required for use in the homes of patients with mobility problems. Patients who require special positioning, the use of special attachments, or the need for elevation of the head of the bed may benefit from a hospital or customized hospital bed. In addition, patients with other risk factors, including patients with cognitive impairments or weakness, may require additional safety measures, such as specialized padding or an enclosed bed to prevent falls and entrapment. In this case, the patient has autism and intellectual disability.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for a Cubby bed.The first line of treatment for sleep problems in pediatric patients with neurodevelopmental disabilities is the promotion of improved sleep hygiene, defined as basic optimal environmental, scheduling, sleep-practice, and physiologic sleep-promoting factors. Sleep hygiene principles emphasize creating a safe, consistent, and appropriate sleep environment tailored to the patient’s specific needs. Environmental modifications are recognized as evidence-based interventions for sleep disturbances in pediatric patients with autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a specialty hospital bed with a lateral tilt function and voice controllability.Patients with physical disabilities such as functional tetraplegia in the setting of long-standing arthrogryposis multiplex congenita are at high risk for pressure injuries. Prevention and treatment include measures such as pressure relieving maneuvers, routine repositioning, skin monitoring, maintaining nutrition, and support surfaces. Lateral positioning can play a role in providing pressure relief, but there is a lack of proven marginal benefit of continuous rotating lateral positioning provided by a hospital bed over lateral positioning provided intermittently by a caregiver.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospital stay for treatment of the enrollee’s acute low back pain without sciatica. Findings: The physician reviewer found that the records demonstrate that this patient had a longstanding history of neck pain, back pain, complaints of generalized weakness, and depression. She was taking multiple analgesics and pharmacotherapeutic medications as an outpatient. She was hospitalized with an exacerbation of her low back pain without report of significant trauma. Examination showed that she was neurologically intact. Imaging showed a small avulsion fracture in the L2 inferior facet that was determined to be an old fracture. There was no clinical history indicating that she had sustained an acute back fracture. There was no clinical correlation on spine palpatory examination.

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