202109-142045
2021
Fidelis Care New York
Medicaid
Orthopedic/ Musculoskeletal
Durable Medical Equipment (DME) (including Wearable Defibrilllators)
Medical necessity
Upheld
Case Summary
Diagnosis: Leg swelling.
Treatment: Compression pump.
The insurer is denied coverage for compression pump.
The denial is upheld.
This female patient has no documented history.
This board-certified physical medicine and rehabilitation/pain management practicing physician relied upon clinical experience and a medical literature review regarding pneumatic compression systems in making the determination. The clinical records submitted do not support the requested durable medical equipment (DME) E0650x1, E0667x2- compression pump as medically necessary. The patient and/or her medical provider(s) do not provide any specific clinical information regarding the underlying diagnosis, result of alternative treatments or response to the requested treatment.
From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information submitted for review, durable medical equipment (DME) E0650x1, E0667x2- compression pump is not medically necessary.
The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.
The carrier's denial of coverage for compression pump is upheld. The medical necessity is not substantiated.