Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe manual wheelchair. We decided that the Plan does not have to pre-approvethe custom accessories. You asked the Plan to pre-approvethe manual wheelchair and accessories. You say that this is medically necessary.The Plan says that the enrollee's needs can be met with other lower cost alternatives.We decided that the Planhas to pre-approvethe manual wheelchair. The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered if there is a mobility limitation that significantly impairs MRADLs, and this cannot be resolved by a cane or a walker.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for the wheelchair. Our reviewer says that the manual wheelchair is medically reasonable and necessary. Our physician reviewer found that based on the medical records provided, there is documentation of a mobility limitation that significantly impairs your ability to complete mobility-related activities of daily living (MRADLs). You are not ambulatory,so this could not beresolved with a cane or a walker. Your home is appropriate for the wheelchair. There is documentation that the manual wheelchair would significantly improve your ability to perform MRADLs. There is documentation that you or a caregiver would be able to propel the wheelchair.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair have been met.Therefore, we decided that the Plan has to pre-approvethe manual wheelchair. We also decided that the Plandoes not have to pre-approvethe custom accessories.The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered if the coverage criteriaare met for them.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for the various custom accessories. Our reviewer says that the requestedaccessories are not medically reasonable or necessary. Our physician reviewer found that there is not a comprehensive written evaluation showing that a prefabricated seating system is not sufficient in the available records. There is no documentation thata standard manual wheelchair with a wedge cushion and/or leg rests would not meet your needs. There is no documentation that you have a reasonable indication for the swing-away/retractable/removable hardware, elevating legrests, adjustable arm height options, or the other accessories variously listed as K0108.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custom accessories have not been met.Therefore, wedecided that the Plan does not have to pre-approvethe custom accessories.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.