Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with the requested power 
options/features. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with the requested power options/features. You 
say that the request for a group 3 power wheelchair with accessories/features is medically necessary. The Plan 
denied your request. The Plan says that there is no need for this requested group 3 power wheelchair with the 
requested power options/features. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 power wheelchair with the 
requested power options/features. Our reviewer says that the request for a group 3 power wheelchair with 
accessories/features is medically necessary. Our physician reviewer found the enrollee is with a medical history 
of diabetes mellitus type II, hypertension, and asthma who suffered an ischemic stroke with left sided 
hemiparesis. A power mobility evaluation was performed on July 18, 2022, and August 11, 2022. The enrollee 
is currently using a group 1 power mobility device that is not meeting her positioning needs. The enrollee is 
non-ambulatory and requires 3 people to assist with walking. She requires maximum assistance with her 
activities of daily living. She has 3/5 motor strength in the right upper extremity and 0/5 motor strength in the 
left upper extremity. The enrollee has 3/5 motor strength in the right lower extremity and 1/5 motor strength in 
the left lower extremity. She has spasticity in affected upper and lower extremities. She is noted to require 
assistance with transfers and has impaired sitting balance. 
 
The enrollee is non-ambulatory and cannot use a cane or walker for mobility given her left sided hemiparesis 
and spasticity. She is unable to functionally propel a lightweight manual wheelchair given that she lacks the strength in her unaffected upper extremity. She is also unable to use a power scooter given that she lacks the 
upper extremity strength and sitting balance to safely operate one. She requires a power wheelchair for mobility 
and accomplishing her daily activities. She requires power tilt and recline, and power elevating leg rests given 
that she cannot independently perform pressure relief and has spasticity of her right lower extremity. She 
requires a group 3 power wheelchair given her stroke, spasticity and increased positioning needs with both 
power tilt and recline and power elevating leg rests, which cannot be met with a group 2 power wheelchair. 
Therefore, the group 3 power wheelchair 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 a group 3 power wheelchair with the requested power options/features have 
been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with the 
requested power options/features.  
 
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.