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201907-119259

2019

Fidelis Care New York

Managed Long Term Care

Central Nervous System/ Neuromuscular Disorder

Durable Medical Equipment (DME) (including Wearable Defibrilllators)

Medical necessity

Upheld

Case Summary

The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair. Power Wheelchair is not medically necessary for this patient. Provider notes that the patient is able to use a walker in the home. The use of an electric scooter/wheelchair outside of the home is not appropriate. If the patient is able to use a walker in the home patient should be capable of using a manual wheelchair outside of the home. Therefore, a customized manual wheelchair is more appropriate and within the generally accepted standards of medical care. The HP determination is upheld.

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