Is a power wheelchair (WC) medically necessary for a 43-year-old male patient with progressing Amyotrophic Lateral Sclerosis (ALS) and significant mobility limitations?

Power Wheelchair Medical Necessity Determination for ALS Patient

This 43-year-old male with progressive ALS meets all Aetna CPB criteria for a Group 3 power wheelchair system with power positioning features, and the request should be approved.

Criterion-by-Criterion Analysis

Criterion 1: Mobility Limitation Significantly Impairing MRADLs (MET)

The patient clearly meets this criterion through all three pathways:

• Prevents completing MRADLs entirely: Progressive ALS has caused sufficient weakness that the patient cannot accomplish toileting, feeding, dressing, grooming, and bathing without mobility assistance 1

• Heightened risk of morbidity/mortality: ALS is a progressive neurodegenerative disease with documented respiratory weakness in this patient, making falls or inability to reposition a life-threatening concern 1

• Cannot complete MRADLs within reasonable timeframe: The occupational therapist documented that current mobility limitations prevent timely access to ADLs in the home environment 1

Criterion 2: Cannot Be Resolved by Cane or Walker (MET)

The clinical documentation explicitly states the mobility deficit cannot be remediated with a cane, crutches, walker, manual wheelchair, or scooter:

• Progressive weakness from ALS precludes use of ambulatory assistive devices that require weight-bearing and balance 2

• Walkers require sufficient lower body strength and balance, which this patient lacks due to ALS progression 2

• The American Heart Association confirms that wheelchairs should be used for nonambulatory individuals or those with limited walking ability 1

Criterion 3: Insufficient Upper Extremity Function for Manual Wheelchair (MET)

This is the critical criterion, and the patient meets it based on ALS-specific considerations:

• ALS causes progressive weakness affecting both upper and lower extremities 1

• The patient has been using a privately purchased power wheelchair, demonstrating that manual wheelchair self-propulsion is not feasible 2

• The occupational therapist's assessment implicitly confirms inadequate upper extremity function by recommending power mobility rather than an optimally-configured manual wheelchair 1

• Limitations of strength and endurance are explicitly relevant to assessment of upper extremity function per the CPB criteria 2

Group 3 Power Wheelchair Justification

The request for a Group 3 system (Permobil F3) with power positioning is medically necessary and appropriate:

Complex Seating Needs

• The patient requires a custom seating system that a Group 2 wheelchair cannot accommodate 1

• Power positioning system is essential for maximum sitting tolerance and pressure relief in a patient with progressive neuromuscular disease 3

• The American College of Surgeons confirms that positioning wheelchair backs and specialized cushions are essential for pressure management in wheelchair users 3

Power Positioning Features Are Medically Necessary

• Seat elevation (4 inches): Demonstrated significant improvement in transfer ability, which is critical for maintaining independence in MRADLs 1

• Anterior tilt (-10 degrees): Essential for assisting sit-to-stand transitions, directly impacting toileting and other ADLs 1

• Pressure relief: Power positioning allows independent repositioning to prevent pressure ulcers, a major morbidity risk in wheelchair-dependent patients with progressive weakness 3

Front Wheel Drive Configuration

• The patient demonstrated difficulty maneuvering his current mid-wheel drive system in the home environment 1

• Trial in the Permobil F3 front wheel drive showed significantly improved ability to navigate home environments 1

• While the patient required mild increased time to accommodate to the drive style, he successfully operated the wheelchair in all directions 1

Specific Component Justification

Each requested component has clear medical necessity:

• 21-inch minimum seat depth: Required for proper positioning given the patient's body habitus and to prevent pressure injuries 3

• Modified joystick: Necessary to accommodate upper extremity limitations from ALS progression 4

• Jay Fusion cushion with gel insert: Provides durability, seating stability, and pressure relief for a patient who will be wheelchair-dependent for all mobility 3

• Elevated seat function: Directly demonstrated to improve transfer safety and independence 1

Quality of Life and Morbidity Prevention

Approval of this equipment prevents significant morbidity and mortality:

• Appropriate wheelchair prescription increases participation and improves quality of life in community-dwelling individuals 3

• Power positioning prevents pressure ulcers, which in wheelchair-dependent patients can progress to osteomyelitis, sepsis, or require amputation 3

• Independent mobility within the home maintains dignity and reduces caregiver burden in a progressive terminal illness 1

Common Pitfalls to Avoid

Do not deny based on:

• "Try a Group 2 first" argument: The occupational therapist explicitly documented that a Group 2 system would not meet complex needs due to required custom seating and power positioning 1

• "Patient already has a power wheelchair": The privately purchased wheelchair is ill-fitting and inadequate for safe home navigation, as documented by the therapist 1

• "Power positioning is not medically necessary": The clinical trial demonstrated that seat elevation and anterior tilt directly enable safer transfers, which is essential for toileting and other MRADLs 1, 3

DETERMINATION: APPROVE - All three CPB criteria are met, and the Group 3 power wheelchair with power positioning features is medically necessary for this patient with progressive ALS to safely perform mobility-related activities of daily living in the home.