Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories.
You asked the Plan to pre-approve a manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories. You say that the requested manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories.
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 a manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories. Our reviewer says that the enrollee does not meet criteria for the requested manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories. Our physician reviewer found the documentation notes the enrollee has a mobility limitation and needs extensive assist for activities of daily living but it is not clear that the mobility limitation is impairing her participation in mobility related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home or that her cognitive function is limiting her participation. The documentation is not clear that her mobility limitation cannot be resolved by the use of an appropriately fitted non custom wheelchair. There is no evidence that the requested wheelchair will significantly improve the enrollee's ability to participate in MRADLs in the home. The documentation is not clear what prefabricated seating system has failed to meet the enrollee's seating and positioning needs. There is no evidence of a past or current pressure ulcer on objective treating physician progress notes or impaired sensation in the area of contact with the seating surface or a detailed treating physician neuromuscular exam that indicate an inability to carry out a functional weight shift or postural asymmetry. There is no indication of spasticity or use of intermittent catheterization. The documentation does not support the medical necessity of a tilt feature. As the documentation does not support the manual adult sized wheelchair with tilt feature (E1161) and custom seating the accompanying accessories 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 manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual adult sized wheelchair (E1161) with tilt feature and custom seating (E2609 and E2617) and wheelchair accessories.