Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair and components including a 
power seating system, manual swingaway wheelchair accessories, an expandable controller with harness and 
electronic connection, a thigh or knee support, a cushioned headrest, a side or hip support, and a positioning 
seat cushion. We decided that the Plan does not have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and components including a power 
seating system, manual swingaway wheelchair accessories, an expandable controller with harness and 
electronic connection, a thigh or knee support, a cushioned headrest, a side or hip support, a positioning seat 
cushion, and a power seat elevation system. You say that the requested wheelchair and components are a 
medical necessity for the enrollee. The Plan says that rules for coverage have not been met. 
 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair and components 
including a power seating system, manual swingaway wheelchair accessories, an expandable controller 
with harness and electronic connection, a thigh or knee support, a cushioned headrest, a side or hip 
support, and a positioning seat cushion.  
 
The Plan follows Medicare rules. The rules say that a power wheelchair is covered when the criteria listed in 
the Medicare rules section have been met. 
 
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 standard power wheelchair 
and components including a power seating system, manual swingaway wheelchair accessories, an expandable 
controller with harness and electronic connection, a thigh or knee support, a cushioned headrest, a side or hip 
support, and a positioning seat cushion. Our reviewer says that the requested wheelchair and components are 
medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has Parkinson's 
Disease with imbalance, dystonia and rigidity, and postural asymmetry. The enrollee is unable to ambulate, 
cannot use a cane or walker to meet his mobility needs, and requires assistance with activities of daily living. 
The enrollee lacks the coordination and grip strength to propel a manual wheelchair and therefore cannot use 
one to meet his mobility needs. The enrollee requires a power wheelchair to accomplish his mobility related 
activities of daily living. A power wheelchair with power tilt and power recline is medically necessary given 
that the enrollee cannot independently perform pressure relief and is at high risk for development of pressure 
sores. Both power tilt and power recline are necessary in order to provide adequate pressure relief and given the 
fact that the enrollee has abnormal muscle tone and restricted range of motion of the hip joints. The enrollee 
requires the requested joystick, hardware and electrical components to operate the power wheelchair. The 
enrollee requires a cushion to accommodate postural asymmetry as well as lateral supports to support the trunk. 
 
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 standard power wheelchair and components have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 3 standard power wheelchair and components 
including a power seating system, manual swingaway wheelchair accessories, an expandable controller with harness and electronic connection, a thigh or knee support, a cushioned headrest, a side or hip support, and a 
positioning seat cushion.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are 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 to 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.