Diagnosis: Cerebrovascular Accident
Treatment: Motorized Wheelchair
The insurer denied the request for the motorized wheelchair.
The health plan's determination is overturned.

The patient is a female with a history of 2 strokes and gait impairment. The most recent stroke left her with loss of balance/coordination, weakness, reduced endurance, severe cramping in the hands and vertigo. The notes also indicate a fall risk score of 90 which is high risk. She lives alone in a one bedroom apartment on the 13th floor.

The requested health service/treatment of a motorized wheelchair is medically necessary for this patient. Mobility assistance may be required for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Some patients may need mobility assistance on a short-term basis, while those with chronic conditions or enduring disabilities may require mobility assistance on a permanent basis. Manual wheelchairs are used for patients who are unable to walk but have sufficient upper extremity function to propel a wheelchair. Power wheelchairs are used for patients who are unable to walk, or have upper extremity impairment, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), spinal cord injury, stroke with dense hemiplegia, severe Parkinson's disease, and amyotrophic lateral sclerosis (ALS). The power operated vehicle is a three or four wheel non-highway motorized transportation system for patients with impaired ambulation. Considering this patient's chronic medical condition, documentation of severe functional limitations, and mobility restrictions, the power wheelchair is appropriate.

The health plan's determination of medical necessity is overturned in whole.