Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with a manual swingaway accessory. 
We decided that the Plan does not have to pre-approve the remaining requested accessories.  
 
You asked the Plan to pre-approve a group 3 power wheelchair with a manual swingaway accessory. You say 
that the power wheelchair and accessories are medically necessary. The Plan says that the wheelchair is being 
requested for use inside a skilled nursing facility and is not a covered benefit. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair with a manual swingaway 
accessory.  
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to a neurological condition; Myopathy; or Congenital 
skeletal deformity. The rules say that one example of a covered indication for swingaway, retractable, or 
removable hardware would be to move the component out of the way so that a beneficiary can perform a slide 
transfer to a chair or bed. 
 
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 with a 
manual swingaway accessory. Our reviewer says that you meet Medicare criteria for coverage of the group 3 
power wheelchair and swingaway accessory. Our physician reviewer found that your mobility deficit is unable 
to be helped by a walker, cane or manual wheelchair due to upper extremity weakness. The documentation 
does reveal that you can safely operate a power mobility device in the home and there is evidence of an 
objective home assessment indicating appropriate measurements. You do have a myopathy and meet criteria 
for the group 3 power wheelchair. Swingaway, retractable, or removable hardware would be appropriate to 
move the component out of the way so that you can perform a slide transfer to a chair or bed if needed. 
 
Our physician reviewer also found that you do not meet Medicare criteria for coverage of the remaining 
accessories requested. Our physician reviewer found that the power tilt and recline criteria have not been met. 
The documentation does not indicate that you utilize intermittent catheterization for bladder management. Your 
other comorbidities would not affect tone or sensation. The Expandable Controller is not medically necessary. 
Your current upper extremity strength is sufficient to allow you to control any power options through their 
individual switches. Your wheelchair does not have a sling/solid seat/back and you do not meet criteria for the 
positioning cushion, mounted headrest and trunk/hip support. The power seat elevation feature is not a covered 
benefit of Medicare or the Plan. Batteries are covered as part of the wheelchair base. 
 
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 with a manual swingaway accessory have been 
met. The record indicates that the group 3 power wheelchair is for use inside your private home and not a 
skilled nursing facility. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair 
with a manual swingaway accessory. We also decided that the Plan does not have to pre-approve the 
remaining requested accessories, based on medical necessity and Medicare coverage rules. 
 
 
 
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.