Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108), power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) (E2361), wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028 x 4), power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (E2313), wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction (E1007), power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311 x 2), wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair (E1010) and custom fabricated wheelchair seat cushion, any size (E2609), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
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 the DME. Our physician reviewer found based on the medical records provided the documentation does not meet the requirements listed in the Local Coverage Determination (LCD): Power Mobility Devices (L33789) for Medicare coverage for the custom power wheelchair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise specified (K0108), power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) (E2361), wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028 x 4), power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (E2313), wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction (E1007), power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311 x 2), wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair (E1010) and custom fabricated wheelchair seat cushion, any size (E2609), for the enrollee.