Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 power operated wheelchair (K0823) and accessories (E0973, E1208, E2365).  You asked the Plan to pre-approve a group 2 power operated wheelchair and accessories. You say that the requested equipment is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the criteria for coverage of the requested equipment have not been met.  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 patient's 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 2 power operated wheelchair and accessories. Our reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer found that this patient has a personal mobility deficit, but the documentation does not reveal that it significantly impairs participation in MRADLs in the home. Currently without an assistive device the patient can move independently from room to room and is independent in feeding, bathing, grooming, upper extremity (UE) and lower extremity (LE) dressing, and toileting. The documentation indicates the patient has full range of motion (ROM) and has been able to use a walker in the past. The documentation is not consistent that the patient is unable to use a walker to assist in participation of MRADLs in the home.  The patient reports that she used a walker in the past but between her shortness of breath and degenerative joint disease/osteoarthritis in her knees she personally feels it would just mean she would have to stop more often than if she had a power chair. There is no detailed objective upper extremity or lower extremity gait or neuromuscular exam with strength, ROM, reflexes, sensation provided by the treating nurse practitioner (NP) supporting limitations in the UE that would not allow this patient to use an assistive device or to corroborate with the WC evaluation showing UE weakness.  The documentation is additionally conflicting as the NP states that a scooter would be sufficient for the patient. The wheelchair assessment (performed by a physical therapist/vendor) states that a scooter is unsafe and would not fit in the home. The patient has the cognitive ability to safely operate a PMD. There is no objective evidence of an upper extremity physical exam by the treating NP that the patient cannot use an assistive device. Given the conflicting information and the fact that the patient is currently able to participate in MRADLs independently and move room to room independently the requested group 2 power wheelchair (K0823) and related accessories are not medically reasonable and 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 a group 2 power operated wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated wheelchair (K0823) and accessories (E0973, E1208, E2365).