Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 power wheelchair (PWC) with power options for the enrollee.
You asked the Plan to provide coverage for the requested power wheelchair and equipment. You say that at the time of the appeal, the requested equipment was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 power wheelchair (PWC) with power options. The medical records show at the time of the appeal the enrollee is a 74-year-old woman with a medical history that includes Pompe's Muscular Dystrophy, diabetes mellitus, chronic renal failure, thyroid cancer, chronic respiratory failure, and osteoarthritis. A power seating system, tilt only, recline only, or combination tilt and recline with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and 2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or 5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 6. The power seating system is needed to manage increased tone or spasticity.
On June 6, 2022, the Face-to-Face wheelchair evaluation states with her history of Pompe's muscular dystrophy the enrollee has progressive, significant lower extremity and pelvic weakness that has become more debilitating over time. Exam limited. Assessment: Diet-controlled DM II, "Chr" response failure with hypercapnia, Malignant neoplasm of thyroid, Lipid screening. On June 9, 2022, the Wheelchair Mobility Assessment and Training states the enrollee spends most of her day in a power lift recliner. Her function declines throughout the day. Sensation is intact. No current pressure sores or history of healed sores. Ambulation ability was 40 feet in 42 seconders with care giver assistance. She has 2+/5 shoulder strength, 3/5 elbow strength, 3/5 wrist strength, 4-/5 hip flex, 3/5 knee strength and 3/5 ankles strength. The documentation does not support that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, or that she utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or that a power seating system is needed to manage increased tone or spasticity. Medicare coverage criteria are not met.
We looked at this physician review, the case file, the reopen and the Medicare rules. We have determined the criteria required for the requested power wheelchair and power options were not met. Therefore, we decided that the Plan does not have to provide coverage for a Group 3 power wheelchair (PWC) with power options for the enrollee.