Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve a Group 3 power wheelchair with attachments. We decided that the Plan does not have to pre-approve a power seating system, combination tilt and recline, with power shear reduction and power elevating leg rests. You asked the Plan to pre-approve a Group 3 power wheelchair with attachments. You say that this is medically necessary for you.The Plan says that that repair can be performed on your old wheelchair.We decided that the Plan has to pre-approve a Group 3 power wheelchair with attachments. The Plan follows Medicare rules. Medicare rules say that if an item of equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment.The file indicates the enrollee has had her power wheelchair for over 5 years and that is has been in continuous use.Therefore, we decided that the Plan has to pre-approve a Group 3 power wheelchair with attachments.We also decided that the Plan does not have to pre-approve a power seating system, combination tilt and recline, with power shear reduction and power elevating leg rests.The Plan follows Medicare rules. Medicare rules say that a power seating system and elevating leg rests are covered if the above criteria are met.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 seating system, combination tilt and recline, with power shear reduction and power elevating leg rests. Our reviewer says that the power seating system, combination tilt and recline, with power shear reduction and power elevating leg rests are not medically reasonable and necessary for the enrollee in this case. The document reveals that the patient has a mobility deficit but the documentation does not reveal that it consistently interferes with MRADLs. The patient was noted to be independent with bed mobility, dressing, grooming, eating, mod independent with toileting and independent but needs excessive time with transfers. She can ambulate with walker up to 50 feet per the DME evaluation. The documentation does not support that this patient is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management or has increased tone or spasticity. The patient does not have a cast, brace, musculoskeletal condition that needs an elevating leg rest. There is no evidence of significant edema of the lower extremities on the medical office visit progress notes. There is no evidence that the patient requires a reclining back on the wheelchair. Our physician reviewer found that the enrollee does not meet the criteria for the power seating system, combination tilt and recline, with power shear reduction and power elevating leg rests.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 seating system, combination tilt and recline, with power shear reduction and power elevating leg rests have not been met.Therefore, we decided that the Plan does not have to pre-approve a power seating system, combination tilt and recline, with power shear reduction and power elevating leg rests.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