Special Chair denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with cerebral palsy. The patient was noted to require assistance for all activities of daily living and required two-person assistance for transferring. The provider noted the patient had a previous fall that resulted in severe brain injury requiring brain surgery. The provider noted the patient is unable to reach items in the classroom and at home due to his inability to stand unassisted. The patient has been treated with physical therapy and uses a manual wheelchair. It was noted the patient ambulates short distances with a reverse Kaye walker with supervision to contact guard assistance. The patient uses hip-knee-ankle-foot-orthosis and ankle foot orthosis. The patient’s parent has requested authorization and coverage for a Dynamic Rifton Pacer Gait Trainer.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested authorization and coverage for a Rifton standing machine.Findings: The physician reviewer found that the enrollee has a diagnosis of hypotonia leading to significant developmental delay. He has been receiving outpatient physical therapy (PT) services with focus on improving overall functional mobility, strength, balance, and development of motor skills. In addition to PT services, he also receives occupational therapy (OT) and speech therapy (ST). He is currently utilizing bilateral supra-malleolar orthosis (SMOs), is non-ambulatory, has no independent mode of mobility, and is dependent for many activities of daily living and mobility skills. The enrollee has decreased muscle strength and low tone throughout his extremities and his trunk. He demonstrates rolling skills.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a PR510 Zero Gravity infinite position MaxiComfort lift chair.Findings: The physician reviewer found that Chu and colleagues report that despite continued research efforts into this group of genetic neuromuscular disease, patients with limb-girdle muscular dystrophy (LGMD) continue to be treated symptomatically with the aim of prevention or addressing complications. Pousada Garcia and colleagues state, “There is a need for a more comprehensive investigation into the role of different kinds of support that can improve the quality of life of persons with neuromuscular disease.” In a study on the effects of different assistive seats, Lou and colleagues report that further studies are needed to examine the biomechanical effects of assisted seats on individuals with disabilities.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a recliner chair with a power lift. The records indicate that this patient has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and low back and leg pain. The provider noted that the patient requires a wheelchair for mobility. The patient has requested a power lift recliner chair with an adjustable back and footrest. As noted in the medical literature, power lift recliner chairs are used for patients who are independent or modified independent with ambulation but cannot independently transfer from a seated to a standing position. There is limited documentation regarding this patient’s level of mobility and function. There is a report that the patient requires a manual wheelchair for mobility and is not independent with ambulation.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Special Chairwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.