Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories. You asked the Plan to pre-approve a Group 2 power wheelchair (K0842), the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377), tilt and recline (E1007), elevating leg rests (E1012), and power seat elevation system (E2300). You say that the enrollee needs a Group 2 power wheelchair and accessories. The Plan denied your request. The Plan says a Group 2 power wheelchair exceeds the enrollee's needs. 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 2 power wheelchair (K0842), the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377), tilt and recline (E1007), elevating leg rests (E1012), and power seat elevation system (E2300). Our reviewer says that the Group 2 power wheelchair is not medically necessary. Our physician reviewer found the enrollee does not meet the requirement for a Group 2 power wheelchair (K0842), the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377), tilt and recline (E1007), elevating leg rests (E1012). The enrollee has a personal mobility deficit that impairs participation in MRADLs but it is not clear that this deficit is unable to be helped by an optimally configured manual wheelchair given the documentation of full range of motion and 5/5 right upper extremity strength and 4-/5 left upper extremity strength. The enrollee can safely operate a PMD. There is no evidence that the enrollee has edema, needs management of spasticity, or performs intermittent catheterization therefore the request for power tilt/recline and elevating leg rests exceeds need. The power wheelchair electronic connection (E2311), expandable controller harness (E2313), and expandable controller (E2377), tilt and recline (E1007), elevating leg rests (E1012) exceeds medical need. The documentation does not indicate that the enrollee requires a proportional input device (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick, a non-proportional input device (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control. The enrollee does not need an expandable controller to be able to operate one or more of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) or an attendant control. The documentation indicates the enrollee has sufficient strength to control the power features through their own individual switches therefore the requested E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary. 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 2 power wheelchair (K0842), the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377), tilt and recline (E1007), elevating leg rests (E1012), and power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.