Appeal type: DME/ Orthotics
Decision: Partially Favorable

You asked the Plan to pre-approve power wheelchair and components. You say that you are appealing with supporting records. The Plan says that the denial of authorization for these items is correct, because the enrollee does not have a medical need for multiple power options, expandable controller, harness, attendant control or power tilt/recline and the other accessories such as joystick armor, backup camera, adjustable receiver, and backup camera bracket are not primarily medical in nature.
We decided that the Plan has to pre-approve power wheelchair with battery, power tilt/recline, power leg elevation, manual swing-aways, heel loop/holder, toe loop/holder, thigh/knee support, positioning back cushion, and skin protection and positioning cushion.
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with multiple power options may be covered if the criteria for a enrollee's mobility deficit is due to a neurological condition, myopathy, or congenital deformity and the enrollee otherwise meets the criteria for a power wheelchair in general and a Group 2 power wheelchair with multiple power options in particular. Medicare rules also state that a battery, power tilt/recline, power leg elevation, manual swing-aways, heel loop/holder, toe loop/holder, thigh/knee support, positioning back cushion, and skin protection and positioning cushion may be covered under certain circumstances for a covered wheelchair. 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 wheelchair and components. Our reviewer says that the enrollee meets the Medicare criteria for the requested power wheelchair with battery, manual swing-aways, power tilt/recline, power leg elevation, heel loop/holder, toe loop/holder, thigh/knee support, positioning back cushion, and skin protection and positioning cushion. Our physician reviewer found the enrollee is non-ambulatory and has spasticity. She is wheelchair bound. The seating evaluation indicates the enrollee requires a Group 3 power wheelchair in order to improve her postural deficits and decrease the risk of pressure injury. She is unable to adjust her own weight and requires a power tilt/recline option, however she is able to wash her hands independently and can use controller sticks. The enrollee has a neurologic disorder with functional deficits. 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 wheelchair with some components have been met. Therefore, we decided that the Plan has to pre-approve power wheelchair the components listed in this section.
We also decided that the Plan does not have to pre-approve an expandable controller, electrical connection, attendant control, upgraded controller harness, headrest, joystick armor, backup camera, stealth height adjustable receiver, and backup camera bracket.
The Plan follows Medicare rules. Medicare rules state that power wheelchair components may be covered under certain circumstances for a covered wheelchair. 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 other components. Our reviewer says that the enrollee does not meet the Medicare criteria for these requested components. Our physician reviewer found that these requested accessories are not medically necessary as the enrollee does have use of her hands and does not require advanced features such as an expandable controller, joystick armor, backup camera, or backup camera bracket. The requested attendant control, upgraded controller harness, and headrest are also 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 these components have not been met. Because the expandable controller is not medically necessary, the requested separate electrical connection (E2311) would not be needed. Therefore, we decided that the Plan does not have to pre-approve the components listed in this section.
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.