Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to pre-approve a Group 2 power wheelchair with battery, armrest, and manual swingaway. 
You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve Group 2 power wheelchair and battery.  
 
The Plan follows Medicare rules. Medicare rules state that a Group 2 power wheelchair may be covered if 
certain criteria are met. Medicare rules state that up to two batteries at any one time are allowed if required for 
a power wheelchair.  
 
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 2 power wheelchair with battery, armrest, and manual swingaway. Our reviewer says that the enrollee meets criteria for the requested Group 2 
power wheelchair. Our physician reviewer found the enrollee has a personal mobility deficit that impairs 
participation in mobility-related activities of daily living. The enrollee's mobility deficit cannot be sufficiently 
and safely resolved by the use of an appropriately fitted cane, walker, or manual wheelchair. There is 
documentation that the enrollee can safely operate a power mobility device. The record documents adequate 
space and surfaces in the enrollee's home for use of the power wheelchair.  
 
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 2 power wheelchair are met. Due to the power wheelchair being 
approved, the requested battery is also allowed. Therefore, we decided that the Plan has to pre-approve Group 2 
power wheelchair and battery.  
 
We also decided that the Plan does not have to pre-approve armrest and manual swingaway. 
 
The Plan follows Medicare rules. Medicare rules state that armrests and manual swingaways may be covered 
for power mobility devices under certain circumstances.  
 
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 armrest and manual swingaway. Our 
reviewer says that the enrollee does not meet criteria for an armrest and manual swingaway. Our reviewer 
found that the records do not document the need for the enrollee to have an arm height that is different from the 
available non-adjustable arms or the need to move the component out of the way so that the enrollee can 
perform a slide transfer to a chair or bed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of armrest and manual swingaway have not been met. Therefore, we decided that 
the Plan does not have to pre-approve armrest and manual swingaway. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.