Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Power Scooter: Pride Go Go Sport (CPT code E1230). 
 
You asked the Plan to pre-approve the power scooter. You say that it is much harder for you to walk any 
distance without it, in the house or outdoors, especially long distance outdoors. You state for outdoor use you 
would not be able to shop for groceries or a mall and it is difficult to go to the doctors office without your 
scooter. You state you have no other means of getting around without your scooter. The Plan denied your 
request. The Plan says the documentation submitted by your physician indicates that you utilize two (2) canes 
for ambulation inside of your home and that you use a power scooter outside of the home for shopping and 
longer distances due to balance issues. The Plan states Medicare requires for coverage of a power scooter that 
you have a mobility limitation that significantly impairs your ability to participate in one or more activities of 
daily living (ADLs) (toileting, feeding, dressing, grooming or bathing), that your mobility limitation cannot be 
sufficiently resolved with the use of a cane or walker, the scooter must significantly improve your ability to 
participate in your mobility-related ADLs, your home must have adequate access for operation of the scooter 
and you must have an onsite evaluation of your home environment to support equipment use. The Plan states 
Medicare also states if any power operated vehicle is only for use outside of the home, it will be denied as not 
covered. 
 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 power scooter. physician reviewer 
found the documentation states you are unable to use a manual wheelchair due to shoulder problems. On April 
18, 2022, mobility assessment states that you are not capable of self-propulsion with a manual wheelchair due 
to weakness from myelopathy and endurance issues. The documentation states, "Is the prescribed equipment to 
be used within the patient's home environment?" The answer was recorded as yes, and then crossed out and 
changed to no. The same document asks the question, "Would the patient's home environment support the use 
of power equipment?" The answer was noted as yes and then crossed out and changed to no. The 
documentation does not support that the requested device will safely fit within your home and significantly 
improve MRADLs in the home. The documentation also does not include a detailed home assessment 
supporting that the requested scooter will fit in the home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Power Scooter: Pride Go Go Sport (CPT code E1230).