Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, and power tilt and power recline options.

You asked the Plan to pre-approve a Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction (E1007), Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012). You say that the enrollee needs a Group 3 power wheelchair, accessories, and power tilt and power recline options. The Plan denied your request. The Plan says a Group 3 power wheelchair with multiple power option is not reasonable and necessary.

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 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction (E1007), Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012). Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found the documentation does not reveal prior or past pressure ulcer or consistent evidence that the patient is at high risk for pressure ulcers therefore the request for power tilt and recline is not medically necessary. The documentation is conflicting on whether the enrollee could safely operate a PMD given the notes indicating that the enrollee has impaired judgement and cognitive deficits. Also the documentation does not reveal a need for the E2377 Expandable Controller and E2313 Expandable Controller Harness. The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the upper extremities with the ability to cut up food and be able to drive a modified van if needed indicates that the patient can control any power options through their own individual switches. The requested Group 3 power wheelchair with multiple power options appears to exceed the patient's medical need.

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 wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861), Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction (E1007), Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012). have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, and power tilt and power recline options.