Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and accessories, for the enrollee.

You asked the Plan to pre-approve a power mobility device and accessories. You say that the durable medical equipment is necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria fora power wheelchair. The Plan states the vendor is offering the enrollee a free upgrade for a more advanced wheelchair; however, the enrollee does not qualify for a power wheelchair as per Medicare criteria.

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 power mobility device and accessories. Our physician reviewer found the power wheelchair, group 2 heavy duty (CPT code K0843), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT Code E2311), expandable controller (CPT Code E2377), harness for upgrade to expandable controller (CPT Code E2313), 22nf sealed lead acid battery (CPT Code E2361), power seating system, combination tilt and recline, with mechanical shear reduction (CPT Code E1007) manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (CPT Code E1028), addition to power seating system, center mount power elevating leg rest/platform, complete system (CPT Code E1012), headrest (CPT Code E0955), wheelchair seat cushion (CPT Code E2602) is not medically necessary. The documentation indicates the patient has a mobility deficit that impairs MRADLs in the home and is not ameliorated by a walker, cane, manual wheelchair due to weakness and poor endurance. While the patient may be able to safely operate a PMD the requested K0843 with multiple power options exceeds the patient's medical need. The documentation does not reveal that the patient needs is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The E2377 Expandable Controller and E2313 Expandable Controller Harness and E2311 are not medically necessary per Medicare Guidelines. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (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, 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 enrollee's strength and function in the upper extremities with the ability feed independently indicates that the enrollee can control any power options through their own individual switches.

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 power mobility device and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device and accessories, for the enrollee.