Diagnosis: Spinal muscular atrophy
Treatment: S5165 home modifications
The insurer denied coverage for S5165 home modifications.
The denial is overturned.

This is a child with a diagnosis of spinal muscular atrophy. The child has associated respiratory failure (ventilator dependent), gastrostomy tube, and neuromuscular hip dislocations. Under review is the medical necessity for S5165 home modifications.

The clinical records support the medical necessity of the requested S5165 home modifications. The patient has a diagnosis of spinal muscular atrophy and is totally dependent for functional mobility. The child is essentially bed bound and wheelchair bound. The child is unable to transfer self independently and requires 1-2 persons for safe transfers. The requested S5165 home modifications are a portable ceiling lift and track system. This system is the most efficient and safest means for lifting and transferring this patient. The reviewed medical literature supports the S5165 home modifications (portable ceiling lift and track system) as superior to a standard Hoyer lift, particularly for decreasing risk of injury and ease of use. From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested S5165 home modifications are more appropriate for decreasing the risk of harm to the patient and caregiver while performing lifting and transferring activities when compared to a Hoyer lift.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The medical necessity for S5165 home modifications is substantiated.