Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessories.

You asked the Plan to pre-approve power seating system, combination tilt and recline, with mechanical shear reduction (E1007), addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012), 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 (E2311) and headrest (E0955). You say that the enrollee needs the accessories. The Plan denied your request. The Plan says the enrollee does not meet criteria because there is no clinical evidence of severe swelling in the lower extremities, no evidence of abnormal muscle tone or spasticity and the electronic connection and headrest are not necessary without the options.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 power seating system, combination tilt and recline, with mechanical shear reduction (E1007), addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012), 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 (E2311). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician supporting documentation does not reveal that the patient has spasticity, utilizes intermittent catheterization, or is incapable of performing a functional weight shift. As the power seating is not medically necessary the E2311 connector is not medically necessary. The documentation does not reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or significant edema of the lower extremities that requires an elevating legrest. The documentation does not support that the criteria in LCD L33792 for the requested items including power tilt/power recline and power elevating leg rest upgrades have been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seating system, combination tilt and recline, with mechanical shear reduction (E1007), addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012), 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 (E2311) have not been met. The headrest (E0955) is not covered. Therefore, we decided that the Plan does not have to pre-approve these wheelchair accessories.