Wheelchair denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ultralightweight wheelchair (HCPCS K0005), skin protection wheelchair seat cushion width 22 inches, any depth (HCPCS E2622), manual wheelchair accessory, pneumatic propulsion tire, any size x 2 (HCPCS Codes E2211), and pneumatic propulsion tire insert x 2 (HCPCS E2213). The records provided for review document that this patient is non-ambulatory due to sacral level spina bifida with chronic paraplegia, as well as due to her talipes equinovarus. She requires a wheelchair to perform all of her mobility-related activities of daily living and instrumental activities of daily living, as well as for community access. The patient’s upper limbs are reported to be functionally intact.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wheelchair accessories [two-sided ABS footrest cover; titanium frame; push handles; Spinergy LX performance wheels; natural fit hand rims; side guards; scissor lock brakes; and/or custom fabricated seat cushion] for the authorized ultra-lightweight manual wheelchair with Smart Drive power assist. This patient presents with a medical history of T6 paraplegia since 1992. The records document that the patient has been experiencing bilateral arm pain and she has a neurogenic bladder. The patient’s provider has recommended a new manual wheelchair. A physical therapy assessment performed on 6/25/23 indicated that the patient’s current wheelchair is old, too small, and falling apart.

Where the denial was upheld

Findings: The physician reviewer found that The patient is a 51-year-old individual with a history of multiple sclerosis. The patient is reported to have been initially diagnosed with multiple sclerosis in 2003 (relapsing-remitting type). Subsequently The patient acquired a COVID-19 infection. The patient is reported to have been hospitalized for approximately one month and experienced paralysis, muscle loss, and weight loss. Records from The patient primary care provider indicated that the patient had diarrhea, right-sided weakness, and multiple syncopal episodes (most likely due to hypovolemia) during hospitalization. The patient was discharged back to the community with a hospital-grade manual wheelchair which was difficult and painful to self-propel due to its weight and configuration.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) power wheelchair accessories including power seating system, center mount elevating leg/platform complete system and power standing system. Findings: The physician reviewer found that Multiple sclerosis is an immune-mediated, demyelinating and neurodegenerative disease of the central nervous system that is a major cause of chronic neurological disability in young and middle-aged adults. Treatment involves controlling acute attacks, managing and preventing underlying disease progression, managing symptomatology, and managing the progressive functional impairments associated with the disease.

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