Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve wheelchair with reclining back and elevating legs rests. We
decided that the Plan does not have to pre-approve the safety positioning belt and anti-tipping device.
You asked the Plan to pre-approve wheelchair with reclining back and elevating legs rests. You say that these
items are medically necessary. The Plan says that the coverage criteria have not been met.
We decided that the Plan has to pre-approve wheelchair with reclining back and elevating legs rests.
The Plan follows Medicare rules. Medicare rules say that a wheelchair with reclining back and elevating leg
rests are subject to the criteria listed in the Medicare rules section.
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 wheelchair with reclining back and
elevating legs rests. Our reviewer says that the requested items are medically necessary. Our physician
reviewer found that the manual wheelchair with reclining back is medically necessary as you have a mobility
limitation that impairs participation in mobility related activities of daily living in the home and is unable to be
alleviated with a cane, walker, or standard wheelchair. The reclining back is needed due to your high risk of
developing a pressure ulcer and inability to effectively perform a weight shift. You have an indication for
elevating leg rests due to her left knee contracture that is unable to bend over 28 degrees.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of wheelchair with reclining back and elevating legs rests have been met.
Therefore, we decided that the Plan has to pre-approve wheelchair with reclining back and elevating legs rests.
We also decided that the Plan does not have to pre-approve the safety positioning belt and anti-tipping
device.
The Plan follows Medicare rules. Medicare rules say that a safety belt/pelvic strap (E0978) is covered if the
beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this
item for proper positioning. Medicare rules say that items and services that are not medically necessary are not
covered.
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 safety positioning belt and antitipping
device. Our reviewer says that the safety positioning belt and anti-tipping device is not medically
necessary. Our physician reviewer found that there is no detailed neuromuscular exam indicating objective
exam evidence of weak upper body muscles, upper body instability or muscle spasticity which requires use of a
safety belt for proper positioning therefore the safety belt does not meet criteria. In addition, the documentation
does not reveal that you will be self-propelling her wheelchair or will be using the wheelchair for climbing
slopes. There is no evidence that you will be providing excessive leaning force on the wheelchair and will not
have a caregiver present to assist her with transfers and propulsion.
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 safety positioning belt and anti-tipping device have not been met. Therefore,
we decided that the Plan does not have to pre-approve the safety positioning belt and anti-tipping device.
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.