Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0858) and accessories 
(E1002, E2300, E2363X2, E2611, E2601, E1012, E0955, E1028X2, E2377, E2313). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need the wheelchair 
with lift because you cannot stand at all by yourself, and you need to be able to stand to do everyday tasks. Due 
to your condition, you have a lesion on your buttocks from sitting and you need the lift to aid in repositioning 
yourself. The Plan denied your request. The Plan says you do not have a qualifying diagnosis causing mobility 
limitation for a group 3 power wheelchair. As the base code for the requested wheelchair is not reasonable and 
necessary, none of the requested accessories can be approved. 
 
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 patients 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 to pre-approve a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
documentation that this 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 enrollees mobility deficit cannot be helped using a walker, cane, or manual wheelchair due to his 
level of weakness and instability. Based on the medical records provided, there is no documentation that the 
group 3 power wheelchair with single power option at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The requested power seat elevation feature is statutorily 
non-covered as it serves no primary medical purpose. Provided records from the enrollees physician does not 
support the vendor's assertion that the enrollee has a musculoskeletal condition or the presence of a cast or 
brace which prevents 90-degree flexion at the knee, or the enrollee has significant edema of the lower 
extremities that requires a power elevating leg rest. Provided records from the enrollees physician do not 
support the vendor's assertion that the enrollee is high risk for skin breakdown, has a history of pressure 
ulcer(s) or has had skin flap surgery. Records from the enrollees physician do not document the enrollee 
performs bladder self-catheterization or that the enrollee has increased muscle tone or spasticity. As the power 
wheelchair base does not meet coverage criteria, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0858) and accessories (E1002, 
E2300, E2363X2, E2611, E2601, E1012, E0955, E1028X2, E2377, E2313).