Is a crutch substitute/knee scooter approved for an elderly patient with a recent open reduction internal fixation (ORIF) surgery for a bimalleolar fracture, given the lack of documentation stating inability to use crutches or standard walkers?

Denial Recommended Based on Insufficient Documentation

This request should be denied because the documentation does not meet the explicit policy requirement that the patient cannot use crutches, standard walkers, or other standard ambulatory assist devices. The policy CM.MED.153 clearly mandates documentation of inability to use standard devices, which is absent in this case.

Policy Requirements Not Met

The insurance policy CM.MED.153 establishes two mandatory criteria for knee scooter approval:

• Criterion A (Met): The patient has a mobility limitation that significantly impairs ability to ambulate - this is satisfied by the bimalleolar fracture status post ORIF requiring non-weightbearing
• Criterion B (Not Met): Documentation must explicitly state the patient cannot use crutches, standard walkers, or other standard ambulatory assist devices - this documentation is completely absent

Critical Documentation Gaps

The current medical record contains:

• No assessment of upper body strength, balance, or coordination needed for crutch use 1
• No documentation of attempted crutch use or trial with standard assistive devices
• No physician statement explaining why standard devices are contraindicated
• The left foot lesion is described as "flat, does not hurt" and non-painful, which does not constitute a contraindication to crutch use

Clinical Context Supporting Standard Devices

The patient's clinical profile actually suggests she could use standard assistive devices:

• The left foot lesion is explicitly documented as non-painful, eliminating the primary concern for crutch use 1
• Post-ORIF bimalleolar fractures routinely achieve successful non-weightbearing with crutches or standard walkers 2
• The patient underwent successful ORIF, indicating adequate surgical candidacy and likely adequate functional status
• No documentation of upper extremity weakness, severe balance impairment, or other contraindications to standard devices 1

Safety Considerations

Knee scooters carry significant injury risks that warrant careful patient selection:

• Mean injury prevalence of 2.5% reported among orthopedic surgeons 3
• 34% of scooter-related injuries required surgical intervention 3
• Most common mechanism is making sharp turns (62% of injuries) 3
• Elderly patients, particularly women, have higher injury rates with scooters 3
• Falls and secondary injuries can compromise the primary surgical repair

Required Documentation for Approval

To approve this request, the ordering physician must provide:

• Explicit statement that patient cannot safely use crutches
• Documentation of specific contraindications (e.g., severe upper body weakness, balance disorder, bilateral upper extremity pathology)
• Evidence of attempted trial with standard devices, if feasible
• Assessment addressing why the non-painful left foot lesion does not preclude crutch use
• Consideration of patient's age and fall risk with scooters versus standard devices 3

Common Pitfall to Avoid

Do not conflate patient preference or convenience with medical necessity. The policy requires documented inability to use standard devices, not simply that a knee scooter would be easier or more comfortable. Insurance coverage is based on medical necessity criteria, not patient preference.

The request should be returned to the ordering physician with a request for the specific documentation required by policy CM.MED.153, criterion 3b.