Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair with multiple power 
options captains chair, patient weight capacity up to and including 300 pounds (K0842) 22 NF sealed lead acid 
battery (E2361) power seating system, combination tilt and recline (E1007) manual swingaway, retractable or 
removable mounting hardware for joystick (E1028) cushioned headrest (E0955) center mount power elevating 
leg rest (E1012) skin protection wheelchair seat cushion (E2603) and electronic connection between wheelchair 
controller and two or more power seating system motors (E2311) expandable controller (E2377) harness for 
upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve the group 2 power wheelchair and upgraded electronics. You say that the 
medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says 
the group 2 power wheelchair to include power tilt/recline and power elevating leg rests exceeds members 
needs for mobility and positioning. 
 
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 patients 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 group 2 power wheelchair and 
upgraded electronics. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found Clinical documentation is not consistent 
regarding diagnosis or assessment. Physician documentation does not list CVA or show that patient has 
neurological weakness (states that patient strength is 5-/5 throughout) although this is listed in the ATP 
assessment. Because physician assessment does not show that the enrollee has neurologic weakness or 
functional weakness which would require a power WC, a group 2 power WC with power function functions 
(K0842), (E2361) (E1007) (E1028) (E0955) (E1012) (E2603) (E2311) (E2377) (E2313) is not medically 
unnecessary. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 group 2 power wheelchair and upgraded electronics have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the group 2 power wheelchair with multiple 
power options captains chair, patient weight capacity up to and including 300 pounds (K0842) 22 NF sealed 
lead acid battery (E2361) power seating system, combination tilt and recline (E1007) manual swingaway, 
retractable or removable mounting hardware for joystick (E1028) cushioned headrest (E0955) center mount 
power elevating leg rest (E1012) skin protection wheelchair seat cushion (E2603) and electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) expandable controller 
(E2377) harness for upgrade to expandable controller (E2313).