Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve group 3 standard power wheelchair, single power option (K0856) 
power seating system, tilt only (E1002) lateral thigh or knee support (E0953) cushioned headrest (E0955) 
manual swingaway, retractable or removable mounting hardware for joystick (E1028) positioning wheelchair 
back cushion (E2613) skin protection and positioning wheelchair seat cushion (E2624) 22 NF sealed lead acid 
battery (E2361) specialty joystick handle for hand control interface (E2323). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that a group 2 power chair 
does not have suspension of the frame which is necessary for management of abnormal muscle tone, spasticity 
and pain. The Plan denied your request. The Plan says that the requested power wheelchair 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 be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a Group 3 power wheelchair can be covered if the medical necessity 
for a power wheelchair is met and if the disorder causing the mobility limitation is a neurological condition, myopathy or congenital skeletal deformity. In this case, the enrollee has a neurologic disorder with functional 
deficits. Criteria for a power wheelchair are met. The documentation does indicate that the enrollee is unable to 
accomplish functional pressure relief which increases her risk for pressure ulcers and she does have spasticity. 
The requested power wheelchair is medically appropriate. 
 
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 wheelchair and accessories have been met. Therefore, we decided 
that the Plan has to pre-approve group 3 standard power wheelchair, single power option (K0856) power 
seating system, tilt only (E1002) lateral thigh or knee support (E0953) cushioned headrest (E0955) manual 
swingaway, retractable or removable mounting hardware for joystick (E1028) positioning wheelchair back 
cushion (E2613) skin protection and positioning wheelchair seat cushion (E2624) 22 NF sealed lead acid 
battery (E2361) specialty joystick handle for hand control interface (E2323).  
 
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.