Diagnosis: G12.9 SMA (spinal muscular atrophy).
Treatment: Power Assist System.

The insurer denied the Power Assist System. The denial is overturned.

The patient is a male with history of spinal muscular atrophy diagnosed a few years after birth and gradually losing strength in his lower extremities and transitioning to using an ultralight manual wheelchair during his early teenage years, which has allowed him to maintain his independence with mobility. He has been using an ultralight manual wheelchair with Smart Drive power assist for many years, but the health plan believes that the patient needs a power wheelchair instead.

The request for a power-assist-system as an add-on to the patient's manual wheelchair is due to wear and tear with several repairs of the Smart Drive power assist in the past. The manufacturer of the Smart Drive has stated that after the last repair that parts for the current model Smart Drive power assist are no longer available with recommendation for a new device.

The patient uses the wheelchair with power assist for navigation at home and in the community. The option of a power wheelchair will not allow him to use the bilateral upper extremities negating rehabilitation principles.

Yes, the Power Assist Program is medically necessary because the Smart Drive power-assist system has been used by the patient, and a replacement is needed as the device could no longer be repaired, as stated by the device manufacturer and also because the power assist to the wheelchair will also enable member to continue to his use his upper extremities to propel the wheelchair and help him maintain strength and dexterity, which he will lose if dependent on using a powered wheelchair. It is also medically necessary because it is not for the convenience of the patient but medically necessary to enable the patient with his condition and extensive weakness to continue to navigate paths, etc towards improving his mobility and accessibility as part of his activities of daily living (ADLs).

In the systemic review of pros and cons of power-assist wheelchair by Kloosterman et al., looking at clinical or randomized controlled trials comparing powered wheelchair with power-assist wheelchair, they found power-assisted propulsion might be beneficial for subjects in whom independent hand-rim wheelchair propulsion is endangered by arm injury, insufficient arm strength or low cardiopulmonary reserves. Also, subjects who have difficulty propelling a wheelchair in a challenging environment can benefit from power-assisted wheelchair use.