Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has pre-approve an expandable control system. We decided that the Plan does not 
have pre-approve a power seat elevation system.  
 
You asked the Plan pre-approve wheelchair options and accessories.. The Plan says that the enrollee is able to 
control the power options using their own switches. 
 
We decided that the Plan has pre-approve an expandable control system.  
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 pre-approve the requested services. Our physician 
reviewer found that the enrollee has a medical history of a T6 incomplete spinal cord injury from a 
thromboembolism. She also has bilateral carpal tunnel syndrome, bilateral rotator cuff injuries, cervical 
spondylosis, and cervical radiculopathy. The patient is non-ambulatory and uses a power wheelchair for 
mobility, which is currently in disrepair and requires replacement. She also has a history of sacral pressure 
sore. She is dependent for transfers. She is unable to ambulate or propel a manual wheelchair given her 
paraplegia from a spinal cord injury as well as impaired upper extremity strength and bilateral carpal tunnel 
syndrome and rotator cuff tendinopathy. While she may not require the power seat elevation feature, she does 
require power tilt and recline and power elevating leg rests for adequate pressure relief given that she is at risk 
for skin breakdown and has a history of a sacral pressure sore. Therefore, the expandable controller is still 
required to operate and accommodate these multiple power options. Therefore, the power wheelchair 
expandable controller is medically necessary.  
 
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 requested services have been met. Therefore, we decided that the Plan has 
pre-approve an expandable control system.  
 
We also decided that the Plan does not have pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.   
 
We looked at the file, and Medicare rules. A power seat elevation feature is non-covered because it is not 
primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a power 
seat elevation system have not been met. Therefore, we decided that the Plan does not have pre-approve a 
power seat elevation system. 
 
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.