Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0856, E2361, E1002, E1012, E2311, E1028x4, E2620, E0955, E0956, E0953, E2607). 
 
You asked the Plan to pre-approve a power wheelchair with multiple power options. You say that you are at 
severe risk for skin breakdown. You are unable to appropriately pressure relieve because you require SBA mod 
assist to stand due to right sided weakness and history of falls. You are unable to be independent with any 
lesser equipment. The requested wheelchair is medically necessary. The Plan denied your request. The Plan 
says you do not have a medical need for a single power option included with the power wheelchair. The 
electronic connection cannot be covered as it is not medically necessary to control the two requested power 
options through the joystick. 
 
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 power wheelchair with multiple power 
options. Our reviewer says that the service is not medically necessary. Our physician reviewer found you have 
a group 3 qualifying diagnosis of a neurological condition. The documentation indicates you have a mobility 
deficit that impairs MRADLs in the home and cannot be overcome with a manual wheelchair, walker, or cane 
due to decreased activity tolerance and weakness. While you may be able to safely use the requested 
wheelchair, the documentation does not reveal that the requested chair with multiple power options is 
medically necessary. The documentation does not reveal that you use a ventilator attached to a wheelchair, is at 
high risk for development of a pressure ulcer. There is no evidence of intermittent catheterization. The 
physician documentation does not indicate objective evidence of spasticity on a BLE physical exam that needs 
a power seating system for management, therefore the request for power tilt exceeds your medical needs. You 
do not require a drive control interface other than a hand or chin-operated standard proportional joystick 
(examples include but are not limited to head control, sip and puff, switch control). The physician 
documentation does not reveal evidence of contractures, bracing, edema in the lower extremities that require 
power elevating leg rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options 
(K0856, E2361, E1002, E1012, E2311, E1028x4, E2620, E0955, E0956, E0953, E2607).