Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261), powered pressure-
reducing air mattress (E0277), group 3 heavy duty powered wheelchair (K0850), and other items/accessories 
(codes E0955, E2606, E2620, E1007, E1028, E2311, E2313, E2376, E2312, and E2361). 
 
You asked the Plan to pre-approve a semi-electric hospital bed, powered pressure-reducing air mattress, group 
3 heavy duty powered wheelchair, and power wheelchair items/accessories. The Plan denied your request. The 
Plan says the medical records received do not support that the enrollee meets the guidelines for the semi-
electric hospital bed and powered pressure-reducing air mattress. The Plan also says that very limited 
information was received, and there were no physician-generated medical records for review for the electric 
powered wheelchair and accessories. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
Medicare rules also say that a group 2 support surface is covered if the beneficiary meets at least one of the 
three criteria listed in the Medicare rules section of this letter.  
 
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 semi-electric hospital bed and 
powered pressure-reducing air mattress. Our reviewer says that the enrollee does not meet the criteria for 
coverage for a semi-electric hospital bed and powered pressure-reducing air mattress. Our physician reviewer 
found the records in this case do not document the enrollee's condition requires position of the body in ways 
not feasible in an ordinary bed, or that the enrollee requires frequent changes in body position or immediate 
changes in body position. The provided records in this case do not document the enrollee requires special 
attachments that cannot be fixed and used on an ordinary bed. Our reviewer found that the records in this case 
do not document the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis which have 
failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer 
treatment program. The records do not document the enrollee has large or multiple stage 3 or 4 pressure 
ulcer(s) on the trunk or pelvis or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or 
pelvis within the past 60 days to meet criteria for the group 2 support surface.  
 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 group 3 heavy duty powered 
wheelchair and power wheelchair accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage for a group 3 heavy duty powered wheelchair and power wheelchair accessories. Our physician 
reviewer found 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 enrollee is reported to be wheelchair bound. Our reviewer also found that based on the medical 
records provided there is no documentation that the enrollee's mobility deficit cannot be helped by the use of a 
manual wheelchair, and there is no documentation that the enrollee can safely operate a power mobility device. 
 
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 semi-electric hospital bed, powered pressure-reducing air mattress, group 3 
heavy duty powered wheelchair, and power wheelchair accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a semi-electric hospital bed (E0261), powered pressure-reducing air 
mattress (E0277), group 3 heavy duty powered wheelchair (K0850), and other items/accessories (codes E0955, 
E2606, E2620, E1007, E1028, E2311, E2313, E2376, E2312, and E2361).