Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair, single power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0856) expandable controller (E2377) 
harness (E2313) electronic connection (E2311) and replacement joystick (E2374). 
 
You asked the Plan to pre-approve the power wheelchair. You say that please find the attached for appeal. The 
Plan denied your request. The Plan says that the enrollee does not have a medical need for the requested group 
3 power wheelchair. The upgraded electronics are not medically needed. Replacement items cannot be 
approved for newly issued wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 the power wheelchair. Our reviewer 
says that the enrollee meets the criteria for the requested power wheelchair. Our physician reviewer found the 
enrollee cannot functionally ambulate due to lower extremity weakness from a stroke and lumbar myelopathy. 
The enrollee cannot use a cane or walker safely for mobility. The enrollee cannot propel a manual wheelchair 
due to upper extremity weakness and spasticity and they cannot use a power scooter given their impaired 
ability to transfer independently and upper extremity weakness and spasticity. The enrollee requires a power wheelchair for mobility and performing daily activities. A group 3 power wheelchair is medically necessary 
since the enrollee requires power tilt for adequate pressure relief and positioning given their weakness and 
difficulty with positioning. The enrollee also requires power elevating leg rests given their lower extremity 
spasticity and edema. The enrollee has had a face-to-face power mobility evaluation performed by a physician 
and a power mobility evaluation performed by a physical therapist. Therefore, the group 3 power wheelchair is 
medically necessary. The replacement joystick, however, is already included with the wheelchair and cannot be 
requested separately. 
 
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 power wheelchair have been met. Therefore, we decided that the Plan has to 
pre-approve a group 3 power wheelchair, single power option, sling/solid seat/back, patient weight capacity up 
to and including 300 pounds (K0856) expandable controller (E2377) harness (E2313) electronic connection 
(E2311).  
 
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.