Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3, power wheelchair with features and 
accessories (K0856, E2361, E1002, E2300, E0955, E1028, E1012, E2377, E2311, E2313, E2609, E2617, 
E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the requested PWC exceeds the enrollee's needs and is not 
reasonable and necessary, per Medicare 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 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
group 3 qualifying diagnosis of a neurological condition. The documentation indicates the patient has a 
mobility deficit that impairs MRADLs in the home. The documentation indicates that the enrollee is unable to 
use a walker, manual wheelchair, or cane due to orthopedic issues, amputation, and deformities of the spine. 
The documentation does not reveal that the enrollee uses a ventilator attached to a wheelchair, is unable to 
perform a functional weight shift, or is at high risk of pressure ulcers. There is no evidence if intermittent 
catheterization. The physician documentation does not indicate objective evidence of spasticity on a BLE 
physical exam that needs a power seating system for management therefore the request for power tilt exceeds 
the enrollee's medical needs. The power elevating leg rests exceed the enrollees medical need and does not 
meet Medicare medical necessity criteria as Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The documentation does not reveal that the enrollee has leg edema, contractures in 
the lower extremities, or inability to flex the knees. The documentation does not reveal that the enrollee 
requires power tilt. The enrollee does not require a ventilator, or non-proportional input devices (e.g., sip and 
puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee has power options on the wheelchair, but he does not need to 
control the power options through a joystick. The enrollees upper extremity strength supports that the enrollee 
can control any power options through their own switches. The E2300 seat elevator is not medically necessary 
as it does not serve a primary medical purpose and does not meet Medicare medical necessity criteria. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3, power wheelchair with features and accessories (K0856, 
E2361, E1002, E2300, E0955, E1028, E1012, E2377, E2311, E2313, E2609, E2617, E1028).