Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the group 3 power wheelchair (K0861, E2361, E1028, E2620, E2605). We decided that the Plan does not have to pre-approve the multiple power options (E1007, E1012, E2311, E2313, E2377).

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan says that there is no medical need for multiple power options.

We decided that the Plan has to pre-approve the group 3 power wheelchair (K0861, E2361, E1028, E2620, E2605).

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 for the wheelchair. Our reviewer says that the requested wheelchair is medically reasonable and necessary. Our physician reviewer found that based on the medical records provided, there is documentation that the enrollee has a personal mobility deficit that impairs participation in mobility-related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. The mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair due to weakness and unstable balance. There is documentation that the enrollee would be able to operate the wheelchair. The enrollee's diagnosis (hemiplegia/hemiparesis) would be considered a qualifying diagnosis for a group 3 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 wheelchair have been met. Therefore, we decided that the Plan has to pre-approve the group 3 power wheelchair (K0861, E2361, E1028, E2620, E2605).

We also decided that the Plan does not have to pre-approve the multiple power options (E1007, E1012, E2311, E2313, E2377).

The plan follows Medicare rules. The rules say that services are covered when they are 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 for the remaining accessories/power options. Our reviewer says that this request is not medically reasonable or necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee needs the various accessories (power tilt and power recline). The records from the prescribing provider do not document a current or past history of a decubitus ulcer or the need for intermittent self-catheterization or the presence of spasticity. 

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 multiple power options (E1007, E1012, E2311, E2313, E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve the multiple power options (E1007, E1012, E2311, E2313, E2377).

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.