Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories.You asked the Plan to pre-approvea Group 3 power wheelchair and accessories. Yousay that the enrollee needs a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says criteria for a Group 3 power wheelchair and accessories have not been met.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 to pre-approve a Group 3 power wheelchair and accessories. Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found the Group 3 power wheelchair (K0861) and accessories: Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377), tilt (E1007) and elevating leg rests (E1012) is not medically necessary.  Per a December 19, 2019 DME consultation the enrolleecan ambulate short distances with a walker but is not a functional ambulator due to lower extremity spasticity. The enrolleecan propel a manual wheelchair but has increased neck pain with prolonged propulsion. The Group 3 power wheelchair exceeds the enrollee'sneeds. The enrolleenotes that it is easier to get around with awalker inside thebathroom as the wheelchair does not fit inside the bathroom therefore does not appear that the requested Group 3 wheelchair will help the enrolleecomplete all MRADLs in the home.Per the DME evaluation the provision of a powered wheelchair with no additional features is indicated to allow the enrollee to independently use public transportation to get to and from medical appointments and the grocery store but this does not indicate that this power mobility device will increase the ability to perform MRADLsin the home. Furthermore, the Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) are not needed as the documentation does not reveal that the enrolleerequires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportionalinput device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength is sufficient to control any power options with their separate switches. The enrolleecan perform independent weight shifts and there is no documentation of a need for a catheter or significant lower extremity edema that requires the E1007 tilt and E1012 leg rests.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 3 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories.