Diagnosis: Left ankle fracture and right sided transfemoral
amputation
Treatment: Durable Medical Equipment: Wheelchair (K0823
x1, K0108 x1)
The insurer denied: Durable Medical Equipment: Wheelchair (K0823 x1, K0108 x1)
The denial is overturned

The patient is an adult female with a medical history of peripheral vascular disease, hypertension, left ankle fracture and right sided transfemoral amputation last year. A wheelchair evaluation from four months ago indicated that the patient currently uses a standard manual wheelchair for mobility that is no longer functioning properly and is in need of replacement. The patient requires minimal assistance at times to complete slide board transfers. She is non-ambulatory and weight bearing as tolerated on her left lower extremity. The patient can propel a manual wheelchair household-distances but requires assistance for community mobility. She requires assistance with her daily activities. The patient has 5/5 motor strength in the upper extremities and 4/5 motor strength in the lower extremities except for below her right transfemoral amputation. The patient trialed a power wheelchair and a home accessibility evaluation was performed 2 months ago. The requested power wheelchair was considered not medically necessary. This decision is being appealed.

The requested power wheelchair is medically necessary.

The patient is an adult female with a medical history of peripheral vascular disease, hypertension, left ankle fracture and right sided transfemoral amputation last year. A wheelchair evaluation indicated that the patient currently uses a standard manual wheelchair for mobility that is no longer functioning properly and is in need of replacement. The patient requires minimal assistance at times to complete slide board transfers.
She is non-ambulatory and weight bearing as tolerated on her left lower extremity. The patient can propel a manual wheelchair household-distances but requires assistance for community mobility. She requires assistance with her daily activities. The patient has 5/5 motor strength in the upper extremities and 4/5 motor strength in the lower extremities except for below her right transfemoral amputation. The patient trialed a power wheelchair and a home accessibility evaluation was performed. The patient cannot ambulate due to a transfemoral amputation and limited function of her contralateral limb due to prior ankle fracture. Therefore, she cannot use a cane or walker for mobility. She can propel a manual wheelchair for short or household distances but does not have the endurance to propel a wheelchair for community mobility. The patient cannot use a power scooter given that she requires assistance for transfers. She is documented to be able to use a power wheelchair and her home is accessible for a power wheelchair. She requires a power wheelchair for mobility and accomplishing her daily activities. The requested power wheelchair is a basic one and meets her basic mobility needs. It would be the most appropriate option given her mobility needs and given her medical conditions.