Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the power seat and skin protectant cushion. We decided that the 
Plan does not have to pre-approve the back cushion, center leg mount, and electronic connection.  
 
You asked the Plan to pre-approve the power seat (E1002), back cushion (E2620), center leg mount (E1012), 
skin protectant cushion (E2608), and electronic connection (E2311). You say the items are medically 
necessary. The Plan says that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve the power seat and skin protectant cushion.  
 
The Plan follows Medicare rules. Medicare rules say that a power seat and skin protection cushion are covered 
when the criteria listed in the Medicare Rules section is met. 
 
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 wheelchair accessories. Our 
reviewer says that the power seat and skin protectant cushion are medically necessary. Our physician reviewer 
found the enrollee is unable to perform a functional weight shift and is at increased risk for skin breakdown 
resulting in pressure sores. The enrollee has decreased sensation in the area of the buttocks, and a previous 
history of skin breakdown with formation of wounds on the buttocks. 
 
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 seat and skin protectant cushion have been met. Therefore, we 
decided that the Plan has to pre-approve the power seat and skin protectant cushion.  
 
We also decided that the Plan does not have to pre-approve the back cushion, center leg mount, and 
electronic connection. 
 
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 the back cushion, center leg mount and 
electronic connection. Our reviewer says that the back cushion, center leg mount, and electronic connection are 
not medically necessary. Our physician reviewer found there is insufficient documentation to support that the 
enrollee has special positioning needs or that the enrollee cannot control the power options with their own 
switches. 
 
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 back cushion, center leg mount and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the back cushion, center leg mount, and 
electronic connection. 
 
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.