Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with power tilt/recline and 
power center foot platform. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with power tilt/recline and power center foot 
platform. You say that the requested group 3 power wheelchair with power tilt/recline and power center foot 
platform is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested group 3 power wheelchair with power tilt/recline and power center foot platform. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria 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 power wheelchair with power 
tilt/recline and power center foot platform. Our reviewer says that the enrollee does not meet criteria for the 
requested group 3 power wheelchair with power tilt/recline and power center foot platform. Our physician 
reviewer found the enrollee appears to be non-ambulatory from a functional perspective and unable to use a 
cane or walker for mobility. The clinical documentation is limited and unclear in terms of his clinical history 
regarding a possible spinal cord injury and the clinical progress note does not provide sufficient documentation 
regarding the enrollees current neurological status, specifically with regards to motor strength, range of motion 
and spasticity. Without this information is not possible to determine if the requested group 3 power wheelchair 
is medically necessary and appropriate, specifically with regards to the enrollees ability to independently 
perform pressure relief and require power tilt and recline as well as the need for power elevating leg rests due 
to potential spasticity. It is not clear if the enrollee has a neurological condition, myopathy or significant 
skeletal deformity that would require a group 3 power wheelchair. There is inadequate clinical documentation 
regarding why he requires power tilt and recline and cannot perform pressure relief. There is also no significant 
lower extremity edema or spasticity that would require power elevating leg rests. Therefore, the group 3 power 
wheelchair with power tilt and recline and power elevating leg rests is not medically necessary at this time. 
 
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 power tilt/recline and power center foot 
platform have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair with power tilt/recline and power center foot platform.