Walker denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a walker with seat and pelvic support. Findings: The physician reviewer found that, as is, the goal with all treatment for cerebral palsy, surgery aims to provide children the greatest chance of living as independently as possible. This patient has been in a power wheelchair and his providers report that he is able to ambulate independently within the home and community settings using a walker with seat and pelvic support. He is noted to be using the walker consistently for 45-60 minutes a day and following through on his physical therapy appointments. The patient’s orthopedic surgeon, pediatrician and physical therapist have reported on the patient’s ability to use the walker within the home and community, as well as frequency of use with consistent improvement.

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a power scooter for treatment of the enrollee’s osteoarthritis. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power scooter. Auger and colleagues performed a literature review of power wheelchair usage and assigned most of the research designs as “very low quality.” Power mobility can benefit specific patients. However, in the present case there is a lack of evidence supporting the medical necessity for power mobility. In this case, the patient has impairment of functional mobility but is able to ambulate throughout the household to perform self-care activities with use of a cane to assist movement. A wheelchair has been requested for impairment of functional mobility by his provider.

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 Walkerwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.