Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve a group 3 power wheelchair with single power options, power tilt
seating option, general use wheelchair seat cushion, and battery. We decided that the Plan does not have to preapprove
positioning accessory, swing away, retractable, or removable hardware, and power connector.
You asked the Plan to pre-approve a group 3 power wheelchair with single power options, power tilt seating
option, general use wheelchair seat cushion, and battery. 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 a group 3 power wheelchair with single power options,
power tilt seating option, general use wheelchair seat cushion, and battery.
The Plan follows Medicare rules. Medicare rules say that these items 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 a Group 3 power wheelchair with single
power options, power tilt seating option, general use wheelchair seat cushion, and battery. Our reviewer says
that the coverage criteria for these items have been met. Our physician reviewer found that you are a 67-yearold
male with a past medical history of polyneuropathy and osteoarthritis who has a decline in functional
mobility. In this case, based on the medical records provided there is documentation that the enrollee meets
criteria for a group 3 power wheelchair with power tilt. A medical note from January 7, 2021, states: "The
patient is at risk for pressure sores due to difficulty performing independent pressure relief." Therefore, because
the coverage criteria for the power tilt seating have been met, the requested Group 3 power wheelchair with
single power options is medically necessary. In addition, based on the Medicare criteria a general use
wheelchair seat cushion and battery are both covered when the base wheelchair is approved.
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 3 power wheelchair with single power options, power tilt seating
option, general use wheelchair seat cushion, and battery have been met. Therefore, we decided that the Plan has
to pre-approve a group 3 power wheelchair with single power options, power tilt seating option, general use
wheelchair seat cushion, and battery.
We also decided that the Plan does not have to pre-approve positioning accessory, swing away,
retractable, or removable hardware, and power connector.
The Plan follows Medicare rules. Medicare rules say that these items 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 positioning accessory, swing away,
retractable, or removable hardware, and power connector. Our reviewer says that these items are not medically
necessary. Our physician reviewer found that based on the medical records provided there is no documentation
that the criteria for coverage of the positioning accessory are met. In addition, there is no medical need for
removable hardware or a power connector.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of positioning accessory, swing away, retractable, or removable hardware, and
power connector have not been met. Therefore, we decided that the Plan does not have to pre-approve
positioning accessory, swing away, retractable, or removable hardware, and power connector.
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.