Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861), an electronic connection (E2311), a power seating system (E1007), and an adjustable angle footplate, large size footplate, and standard size replacement footplate.
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. You say that the enrollee meets criteria for the requested group 3 power wheelchair with multiple power options (K0861), the electronic connection (E2311), the power seating system (E1007), and the adjustable angle footplate, large size footplate, and standard size replacement footplate are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair with multiple power options (K0861), the electronic connection (E2311), the power seating system
(E1007), and the adjustable angle footplate, large size footplate, and standard size replacement footplate are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 group 3 power wheelchair with multiple power options and accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair with multiple power options (K0861), the electronic connection (E2311), the power seating system (E1007), and the adjustable angle footplate, large size footplate, and standard size replacement footplate are not medically necessary. Our physician reviewer found the Group 3 power wheelchair with multiple power options is not medically necessary per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) and LCD L33789. The enrollee has a mobility limitation that impairs participation in mobility related activities of daily living (MRADLs) in the home and is unable to be helped by a cane or walker due to weakness, shoulder pain, poor activity tolerance. The enrollee may be able to safely use the requested wheelchair however the request exceeds the enrollee's needs. The enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. As the power seating system (E1007) is not medically necessary the enrollee does not require the E2311 to control two or more power options through the joystick. As the tilt and recline is not medically necessary the K0861 Group 3 power wheelchair and the footplate and accessories are also not 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 group 3 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861), an electronic connection (E2311), a power seating system (E1007), and an adjustable angle footplate, large size footplate, and standard size replacement footplate.