Diagnosis: Cerebral Palsy, spastic quadriplegia
Treatment: K0108 - Wheelchair Component or Accessory, NOS (six)
E2331 - Power Wheelchair Accessory(attendant control)
E2300 - Wheelchair Accessory, Power seat Elevation System
The insurer denied the K0108 - Wheelchair Component or Accessory, NOS (six)
E2331 - Power Wheelchair Accessory(attendant control)
E2300 - Wheelchair Accessory, Power seat Elevation System
The denial is overturned

This is a male child with cerebral palsy, spastic quadriplegia, Gross Motor Function Classification System (GMFCS) V, and periventricular leukomalacia. The child has been evaluated for seating and mobility options by the qualified healthcare providers and has been recommended use of power wheelchair with accessories. The child underwent a six week power mobility trial that has shown to improve independence. Following review by the health plan, the requested wheelchair accessories E2331(attendant control), E2300 (power seat elevation) and K0108 (power control wheelchair accessory) have been denied due to lack of medical necessity. A letter of appeal has been provided by the treating physical therapist

Yes, the proposed treatment, accessories E2331 (attendant control) and K0108 (power control wheelchair accessory) and E2300 (power seat elevation), is medically necessary.
Based on the review of medical records, this child has been approved to receive a power mobility system. The child's condition (i.e. cerebral palsy, Gross Motor Function Classification System [GMFCS V]) limits independent use of power mobility; therefore this child's clinicians have recommended use of both emergency stop and safety precautions permitting the attendant to control wheelchair operation. In addition, the child has difficulties shifting weight in the chair independently and the power set elevation would enable the child to relive pressure and prevent skin breakdown. Based on the review of clinical records and standards of care in the field of pediatric rehabilitation medicine, prescription of the above mentioned items should be considered as medically necessary in this specific case.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The Health plan did act reasonably in permitting the prescription for power mobility wheelchair for this child who has been evaluated by the skilled healthcare providers. The Health plan initial decision in the denial of the requested wheelchair accessories E2331 (attendant control), E2300 (power seat elevation) and K0108 (power control wheelchair accessory) are not reasonable taking into consideration safety and complication prevention aspects of power mobility prescription for the child with cerebral palsy Gross Motor Function Classification System (GMFCS) V and well supported statements by the direct clinical providers.