Walkaide Functional Electrical Stimulator denials in California external review

What the reviewers wrote

Where the denial was overturned

A 52-year-old female has requested coverage for a WalkAide functional electrical stimulator for treatment of her drop foot secondary to multiple sclerosis. Findings: Three physician reviewers found that the patient was diagnosed with multiple sclerosis nine years ago and has been experiencing problems with foot drop. She reports that she now has trouble walking and has experienced frequent falls. She currently uses a walker, even in the home. The patient has undergone physical therapy and has worn an over the counter brace. The patient’s provider reports the patient has an unsafe and inefficient gait pattern due to her foot drop and that the use of an ankle foot orthosis (AFO) has been unsuccessful in treating her foot drop. The provider recommended the WalkAide functional electrical stimulator.

A 48-year-old male has requested a WalkAide functional electrical stimulator (FES) for treatment of his foot drop status post cerebral vascular accident (CVA). Findings: The physician reviewer found that the patient is is reported to have residual hemiparesis since a prior stroke, with foot drop for the last 21 years. He has a mechanical heart valve due to prior endocarditis and is maintained on Coumadin. He has used an ankle foot orthosis (AFO) for several years. A trial of WalkAide functional electrical stimulator (FES) has been completed, with reported marked improvement in walking speed by 57%. At baseline, the patient is active, ambulatory, but has difficulty walking on uneven surfaces, ramps and stairs. In a six-minute timed walk, he covered 100 yards, but with the WalkAide device he covered 500 yards, without taking breaks.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the WalkAide functional electrical stimulator (FES) for treatment of the enrollee’s hereditary spastic paraplegia. Findings: The physician reviewer found that the request for the WalkAide FES is not medically necessary for treatment of this patient’s medical condition. A review of the peer-reviewed medical literature reveals that the WalkAide can be used in spinal cord injury patients for walking in the home after the patient has completed an adequate trial of physical therapy with the device over a period of three months. This trial period can allow the patient’s provider to properly evaluate the patient’s safety and ability to use the device for the long-term.

A 70-year-old female enrollee has requested a WalkAide functional electrical stimulator for treatment of her hemiparalysis. Findings: Two physician reviewers found that there is limited research on the benefits of functional electrical stimulation (FES) over use of a standard ankle foot orthosis (AFO) for foot drop. Studies performed to date have involved small numbers of subjects. In order to demonstrate the clinical need for a neuroprosthesis for foot drop, it is necessary to demonstrate that the device significantly improves gait mechanics or is significantly better tolerated than standard bracing techniques in a given individual. In the case under review, the patient’s gait has not been fully assessed and it does not appear that standard therapies have been exhausted.

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 Walkaide Functional Electrical Stimulator, then check the rights and deadlines that apply to your plan.