Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve group 3 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040). We decided that the Plan does not have to pre-approve expandable controller (E2313, E2311, E2377), skin protection seat cushion (E2622), removable hardware (E1028), and positioning back cushion (E2613).

You asked the Plan to pre-approve group 3 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040). You say that this equipment is medically necessary for the enrollee's condition. The Plan says that the power tilt and recline feature is not medically necessary. Therefore, the base wheelchair will not be covered, and the requested accessories will be denied.

We decided that the Plan has to pre-approve group 3 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040).

The Plan follows Medicare rules. Medicare rules say that the requested equipment is subject to the criteria listed in the Medicare rules section.

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 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040). Our reviewer says that this equipment is medically necessary. Our physician reviewer found that in this case the enrollee has impaired sensation which predisposes him for pressure sores and is at high risk with difficulty weight shifting. Therefore, the criteria for a power tilt seating system have been satisfied. Subsequently the requested group 3 wheelchair with multiple power options have also satisfied the criteria requirements in this case.

Regarding the cushioned headrest, because the requested power tilt seating system is necessary the cushioned headrest will also be considered medically necessary. The power wheelchair battery is also included when the base wheelchair is covered as it is in this case. Finally, the adjustable angle footplate will be covered since the power tilt seating system is a covered benefit.

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 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040) have been met. Therefore, we decided that the Plan has to pre-approve group 3 wheelchair with multiple power options (K0861), power tilt seating system (E1007, E1012), power wheelchair battery (E2359), cushioned headrest (E0955), and adjustable angle footplate (K0040).

We also decided that the Plan does not have to pre-approve expandable controller (E2313, E2311, E2377), skin protection seat cushion (E2622), removable hardware (E1028), and positioning back cushion (E2613).

The Plan follows Medicare rules. Medicare rules say that the requested equipment is subject to the criteria listed in the Medicare rules section. 

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 expandable controller (E2313, E2311, E2377), skin protection seat cushion (E2622), removable hardware (E1028), and positioning back cushion (E2613). Our reviewer says that these accessories are not medically necessary. 

Regarding the expandable controller, our physician reviewer found that his strength was described as 4/5 in the affected upper extremity from stroke and should not need a joystick and an expandable controller. Hence it is not medically necessary.

Regarding the skin protection seat cushion, the enrollee has not had documented pressure sores. Whether or not he had this cushion in his old chair is not found in the records to make this item eligible for coverage. 

The removable hardware requested is not medically necessary as it is not clear from the documentation that these items are necessary.

Finally, the positioning back cushion is not medically necessary as there is no documentation of any significant postural asymmetries. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller (E2313, E2311, E2377), skin protection seat cushion (E2622), removable hardware (E1028), and positioning back cushion (E2613) have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2313, E2311, E2377), skin protection seat cushion (E2622), removable hardware (E1028), and positioning back cushion (E2613).

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.