Diagnosis: Diabetic foot ulcer.

Treatment: Power wheelchair.

The insurer denied coverage for a power wheelchair.

The denial is upheld.

This is a male patient with diabetes mellitus, peripheral neuropathy and diabetic foot ulcer. Currently under review is the request for a power wheelchair.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the clinical records do not support the medical necessity of the requested power wheelchair. The insurer denied the requested wheelchair due to lack of documentation regarding whether the patient's home can provide adequate access between rooms, in and out of the home, maneuvering space, over surfaces, and a secure storage space for the operation of the power wheelchair. The Home Assessment Evaluation Form completed by the supplier confirms the patient's bathroom and kitchen are not wheelchair accessible. In addition, the treating providers do not address alternatives such as a manual wheelchair and/or using off-loading lower extremity bracing. In addition, the most recent office visit note from the podiatrist indicated the patient's foot ulcer was improving with the use of a total contact cast and without the use of a power wheelchair.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient; the requested power wheelchair is not medically necessary.

The carrier's denial of coverage for a power wheelchair is not substantiated. The insurer's denial is upheld.