Appeal type: DME/ Orthotics
Decision: Partially Favorable

You asked the Plan to pre-approve group 3 power wheelchair with options, accessories, and seating. You say
that the enrollee needs the suspension of a group 3 power wheelchair and the use of the power recline. The Plan
says that the denial of authorization for this wheelchair and components is correct, because the enrollee does
not meet the criteria for a Group 3 power wheelchair with multiple power options and therefore the associated
components are not covered.

We decided that the Plan has to pre-approve group 3 power wheelchair (K0861), power seating
tilt/recline system (E1007), power leg elevation system (E1012), battery (E2359), adjustable foot
plate(K0040), manual swingaway (E1028), positioning cushion (E2620), skin protection cushion (E2607),
and headrest cushion (E0955).

The Plan follows Medicare rules. Medicare rules state that power wheelchairs, accessories, options, and seating
may be covered under certain conditions when they are medically reasonable and necessary.

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 group 3 power wheelchair with options,
accessories, and seating. Our reviewer says that the enrollee meets the Medicare criteria for the requested group
3 power wheelchair, power seating tilt/recline system, battery, manual swingaway, power leg elevation, and
adjustable foot plate, positioning cushion, skin protection cushion, and headrest cushion. Our physician
reviewer found the enrollee has cerebral palsy, is not a functional ambulator, and requires the power wheelchair
to participate in one or more mobility-related activities of daily living. He has documented upper extremity and
lower extremity contractures which necessitate the power seating tilt/recline system. Medicare coverage allows
up to 2 batteries for a power wheelchair. The manual swingaway can move the component out of the way
allowing the enrollee to slide transfer to a chair or bed. The power leg elevation and adjustable foot plate are
medically reasonable and necessary. The documentation supports that the enrollee has impairments of the trunk
and spine, and bilateral upper and lower extremity contractures which would impair his ability to carry out
functional weight shifts, therefore he meets the criteria for a positioning cushion, headrest cushion, and skin
protection cushion.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of group 3 power wheelchair with these options, accessories, and seating have
been met. Therefore, we decided that the Plan has to pre-approve group 3 power wheelchair with these options,
accessories, and seating.

We also decided that the Plan does not have to pre-approve the requested power seat elevation feature
(E2300), electrical connection (E2311), expandable controller (E2377), expandable controller harness
(E2313), push handles (K0108), and manual swingaway joystick mount (E1028 component).

The Plan follows Medicare rules. Medicare rules state that power wheelchairs, accessories, options, and seating
may be covered under certain conditions when they are medically reasonable and necessary. A power seat
elevation feature is considered not primarily medical in nature and is not covered.

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 some options and accessories. Our
reviewer says that the enrollee does not meet the Medicare criteria for the requested power seat elevation
feature, electrical connection, expandable controller, expandable controller harness, push handles, and manual
swingaway joystick mount. Our reviewer found that the electrical connection, expandable controller,
expandable controller harness, push handles, and manual swingaway joystick mount are not medically
reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these options and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve these other options and 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.