Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion (E2609) 
and custom fabricated seat back cushion (E2617). 
 
You asked the Plan to pre-approve a wheelchair seat cushion and seat back cushion. You say that the requested 
items are medically necessary. The Plan denied your request. The Plan says the requested cushions are not 
deemed medically necessary. 
 
The Plan must follow Medicare rules. 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 a wheelchair seat cushion and seat back 
cushion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found provided records do not document the enrollee has 
significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning 
cushions as required by the Local Coverage Article - Wheelchair Seating - Policy Article - A52505. Provided 
records contain conflicting opinions from evaluating therapist as to whether custom fabricated or prefabricated 
cushions will meet her needs. Letters of medical necessity, certificates of medical necessity and the equipment 
prescription report are needed for the custom cushions but no records from the enrollees treating physician 
have provided documenting needs for the custom fabricated cushions. As stated in the Local Coverage Article, 
"Supplier-produced records, even if signed by the treating practitioner, and attestation letters (e.g., letters of 
medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates 
and forms, including CMS CMNs, are subject to corroboration with information in the medical record. A 
prescription is not considered to be part of the medical record. Medical information intended to demonstrate 
compliance with coverage criteria may be included on the prescription but must be corroborated by information 
contained in the medical record. The beneficiary's medical record must contain sufficient documentation of the 
beneficiary's medical condition to substantiate the necessity for the type and quantity of items ordered and for 
the frequency of use or replacement (if applicable). The information should include the beneficiary's diagnosis 
and other pertinent information including, but not limited to, duration of the beneficiary's condition, clinical 
course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc." 
 
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 wheelchair seat cushion and seat back cushion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion (E2609) and 
custom fabricated seat back cushion (E2617).