Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0856), and accessories (CPT code(s): E2361, E1002, E1028, E2620, E0955, E1012, K0108, E2311, and E2607), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee lives in an assisted living facility. You state the enrollee is diagnosed with Parkinson's disease and it has affected the enrollee's gait and ambulation. You state the enrollee experiences bilateral upper extremity tremors, weakness, and pain. The Plan denied your request. The Plan says while this enrollee does have Parkinson's disease, they are still able to stand and make functional weight shifts allowing the enrollee the ability to offload pressure from their lower back and sacrum. The Plan states the enrollee may qualify for either a group 1 or a group 2 power wheelchair but does not meet the Medicare criteria for a group 3 power wheelchair, and the Plan did not find any unique needs that would qualify for a special exception to the Medicare medical criteria.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not 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 the DME. Our physician reviewer found based on the medical records provided there is documentation that this enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is documentation that the enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to the enrollee's level of weakness. There is documentation that the enrollee can safely operate a power mobility device. Records do not, however, document that the enrollee meets criteria for a group 3 power wheelchair with a single power option as records do not document: 1. That the enrollee requires a drive control interface other than a hand or chin-operated standard proportional joystick. 2. That the enrollee uses a ventilator. 3. That the enrollee is at high risk for development of a pressure ulcer, and is unable to perform a functional weight shift. 4. That the enrollee performs intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed. 5. That the enrollee has increased muscle tone or spasticity.

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0856), and accessories (CPT code(s): E2361, E1002, E1028, E2620, E0955, E1012, K0108, E2311, and E2607), for the enrollee.