Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842) and accessories.

You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options (K0842) and accessories. You say that the requested group 2 power wheelchair with multiple power options (K0842) and accessories is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 2 power wheelchair with multiple power options (K0842) and accessories.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 group 2 power wheelchair with multiple power options (K0842) and accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 2 power wheelchair with multiple power options (K0842) and accessories. Our physician reviewer found the documentation is conflicting that the enrollee has a mobility deficit that impairs MRADLs in the home and is not ameliorated by a walker, cane, manual wheelchair due to upper extremity weakness. The occupational therapy (OT) note documents a mobility limitation that interfered with MRADLs, but the physician document is conflicting and notes that the enrollee has no weakness, no difficulty with gait on the review of systems. While the enrollee may be able to safely operate a PMD the requested K0842 with multiple power options exceeds the enrollee's medical need. The documentation does not reveal that the enrollee is a high risk for development of a pressure ulcer and is unable to perform a functional weight shift as the physician documentation does not note prior skin issues and the enrollee is able to independently transfer from wheelchair (WC) to commode and WC to bed and is independent in stand pivot transfers. The enrollee does not utilize intermittent catheterization for bladder management or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength and functional ability with ability to reach into cabinets for meal prep should be sufficient to control any power options through their own switches. Furthermore, the E2300 seat lift is not medically necessary as this does not serve a primary medical need. The OT did not recommend a tilt and recline, and the physician documentation does not indicate specifics on why a tilt and recline are medically necessary. The documentation does not reveal that tilt and recline are medically necessary therefore the requested wheelchair with multiple power options is 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 group 2 power wheelchair with multiple power options (K0842) and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842) and accessories.