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), group 
34 sealed lead acid battery, each (CPT code E2359), and power seating system, tilt only (CPT code E1002). 
 
You asked the Plan to pre-approve the DME. You say that you are unable to walk well; you are unable to 
perform activities of daily living, you have seizures, unsteady gate, paralysis to left arm and have fallen 
multiple times which is why the wheelchair is being requested for this member and the electric portion of the 
wheelchair is due to the paralysis of your left arm which makes it hard for you to manually activate the 
movement of a standard wheelchair. The Plan states you would be at risk for fall and brain injury as well as 
possible death and you had a recent head injury from a fall. The Plan denied your request. The Plan says your 
request is not medically necessary because your records do not show documentation as to your ability to safely 
maneuver a power wheelchair or your caregivers inability to push you in a manual wheelchair, nor 
documentation of an assessment of your homes ability to accommodate a power wheelchair, nor documentation that you or your caregivers can safely transfer you into and out of a power wheelchair. The Plan 
states your doctor recommended you use a walker, but you said you did not like to do so. 
 
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 DME. Our physician reviewer 
found the documentation does indicate that you have a mobility deficit that impairs MRADLs in the home. The 
documentation states that you cannot manual wheelchair due to weakness, and that you currently use a cane but 
is unsteady therefore a cane or walker would not be effective. The documentation does not support that you can 
safely use the requested wheelchair as the documentation indicates that you have multiple seizures per day. 
Also, the documentation is not clear that you cannot be propelled in a manual wheelchair by a caregiver. For 
these reasons the requested wheelchair and accessories are not medically necessary. 
 
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), group 34 sealed lead acid battery, each (CPT code 
E2359), and power seating system, tilt only (CPT code E1002).