Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the elevating leg rest. We decided that the Plan does not have to pre-approve the seat cushion and positioning belt.
You asked the Plan to pre-approve the seat cushion, elevating leg rest and positioning belt. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan says that the medical necessity of the skin protection seat cushion (E2604) is not established, the request for elevating leg rests (E0990) is not supported and the requested positioning belt/safety belt/pelvic strap is inclusive in the base allowance for the power wheelchair.
We decided that the Plan has to pre-approve the elevating leg rest.
The Plan follows Medicare rules. Medicare rules say that elevating leg rests are covered if the beneficiary has significant edema of the lower extremities that requires an elevating leg rest.
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 seat cushion, elevating leg rest and positioning belt. Our reviewer says that you have significant lower extremity edema with weakness in both legs. Treatment of edema is multifactorial but includes elevation of the legs. The requested elevating leg rests are 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 elevating leg rest have been met. Therefore, we decided that the Plan has to pre-approve the elevating leg rest.
We also decided that the Plan does not have to pre-approve the seat cushion and positioning belt.
The Plan follows Medicare rules. Medicare rules say that a skin protection seat is covered for a beneficiary who has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface or Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift. 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 seat cushion and positioning belt. Our physician reviewer found there is no documentation to indicate that you are at increased risk for skin breakdown or that you are unable to adjust your position in the chair independently. Furthermore, there is no indication that you have a current pressure ulcer. The requested skin protection seat cushion is not medically necessary.
Additionally, the requested positioning belt is included in the approved wheelchair base.
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 seat cushion and positioning belt have not been met. Therefore, we decided that the Plan does not have to pre-approve the seat cushion and positioning belt.
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.