Issued and entered December 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On July 1, 2002 the Petitioner, XXXXXXXX, filed a request for external review with the Commissioner of Financial and Insurance Services under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. After a review of the material submitted, the Commissioner accepted the request. The issue involved is medical in nature. The Commissioner therefore assigned it to an independent review organization (“IRO”) on July 9, 2002. On July 25, 2002, the IRO provided its recommendation to the Commissioner.

II
FACTUAL BACKGROUND

The Petitioner’s 11 year-old son was born with multiple disabilities due to a chromosomal abnormality and has severe cognitive impairments. At age 11 he is just learning to walk short distances independently, to use his hands and to complete simple tasks.
The son’s doctor prescribed seven items of durable medical equipment (“DME”). Respondent insurer, Blue Cross and Blue Shield of Michigan (“BCBSM”) denied payment for this equipment because it did not meet the DME requirement. The Petitioner believes that the seven items of DME he purchased for his son meet all of BCBSM’s requirements should be a payable benefit.

III
ISSUE

Is BCBSM is required to pay for the seven items of DME purchased for the Petitioner’s son?

IV
ANALYSIS

Petitioner’s Argument

The Petitioner argues that all seven items he purchased for his son meet the criteria for DME. He has provided equipment descriptions, charges, prescriptions and letters of necessity for all these items but BCBSM continues to deny coverage. He does not understand what other information he can provide to convenience BCBSM to pay for this care.

The son’s doctor indicated that in order to continue to develop the Petitioner’s son’s mobility and to develop strength and coordination, swimming and aqua therapy are recommended. These activities require a floatation device to insure his safety and allow him to exercise his legs and arms.

In order to allow Petitioner’s son further independence and to help improve both hand use and cognitive skills, Dr XXXXX recommended a cordless switch to allow him to operate electrical devices independently. In order to use the cordless switch with appliances that are plugged into outlets, Petitioner’s son also requires a Powerlink to connect the appliance to the receiver for the cordless switch. Finally, in order to use a computer, an adapted mouse is required.

Petitioner’s son is orally defensive and has a strong, involuntary impulse to close his mouth when someone tries to introduce an object into his mouth. This makes brushing his teeth very difficult, which can endanger his dental health. The doctor recommends the use of a dental mouth prop to keep his mouth open during tooth brushing.

The total cost of these items is around $600.00.

BCBSM’s Argument

BCBSM states the Petitioner is ensured under BCBSM’s Community Blue Group Benefit Certificate. Under this certificate, DME is a covered benefit. The certificate requires all DME to be medically necessary in order to be a covered benefit.

BCBSM’s medical consultant reviewed the documentation provided in this case and could not find any evidence that the items purchased for Petitioner’s son were used for a medical purpose. Therefore, BCBSM argues that the items in question failed to meet specific criteria for DME coverage are ineligible because they are not medically necessary for treating the patient’s condition.

Independent Review Organization (IRO) Recommendation

The IRO did not find any peer-review studies showing medical benefit for the Petitioner’s son for the electronic devices provided in this case. The review of the denial letters and the contract benefits supports the BCBSM position that the seven items of DME are not a covered benefit. Of the seven items in question only the mouth prop has a medical justification, but it is not an item considered to be DME.

Commissioner’s Review

The certificate of coverage controls the analysis of whether the seven items provided the Petitioner’s son are payable benefits. DME is a covered benefit under the Petitioner’s certificate and is defined as:

Equipment that can withstand repeated use for a medical purpose by a patient who is ill or injured.

The DME section of the certificate also states:

We do not pay for:

• Exercise equipment and hygiene equipment, such as exercycles, Moore Wheel, bidet toilet seats and bathtub seats.

BCBSM’s medical consultant found the documentation submitted by the Petitioner did not support the position that the cordless switch, cordless receiver, Powerlink control unit, and trackball had a medical purpose. The Aquajogger and Versa Float are exercise equipment and the mouth prop was hygiene equipment and therefore expressly excluded under the certificate.

The IRO concurred with the BCBSM medical consultant and found the equipment was not medically necessary except for the mouth prop. However, this device also was not covered since it was for the purpose of hygiene. The IRO supported BCBSM’s denial of all seven items. The Commissioner accepts the IRO findings and agrees the seven items are not covered under the Certificate.

V
ORDER

The final adverse determination of BCBSM is upheld. BCBSM is not required to pay for the seven items in question in this case.
This is a final decision of an administrative agency. Under MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.