Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual adult size wheelchair, includes tilt in space 
(E1161) manual swingaway, retractable or removable mounting hardware for joystick, other control interface, 
or positioning accessory (E1028) elevating leg rests, pair (K0195) solid support base that is used with a manual 
wheelchair (E2231) foam caster tire any size each (E2219) adjustable height, detachable armrest, complete 
assembly, each (E0973) anti-tipping device (E0971) general use wheelchair seat cushion, width less than 22 
inches, any depth (E2601) prefabricated general use back cushion (E2611) headrest, cushioned, any type, 
including fixed mounting hardware (E0955). 
 
You asked the Plan to pre-approve the manual tilt in space wheelchair and accessories. You say that the 
medical records provided support the necessity of the requested services in dispute. The Plan denied your 
request. The Plan says the provided records does not show that the enrollee meets all of the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 manual tilt in space 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 in this case the documentation does not consistently 
support that the enrollee has a need for a manual wheelchair with all the requested accessories.  The provider's 
documentation indicates the enrollee uses a walker with a slow and shuffling gait, but the physical therapy 
notes that the enrollee is a nonfunctional ambulator. The documentation does not support that the enrollee 
would require swingaway or retractable or removable hardware. The enrollee may require a manual wheelchair, 
but more consistent documentation is required. Additionally, the documentation does not support the need for a 
manual wheelchair with all the requested accessories. 
 
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 manual tilt in space wheelchair and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the manual adult size wheelchair, includes tilt 
in space (E1161) manual swingaway, retractable or removable mounting hardware for joystick, other control 
interface, or positioning accessory (E1028) elevating leg rests, pair (K0195) solid support base that is used with 
a manual wheelchair (E2231) foam caster tire any size each (E2219) adjustable height, detachable armrest, 
complete assembly, each (E0973) anti-tipping device (E0971) general use wheelchair seat cushion, width less 
than 22 inches, any depth (E2601) prefabricated general use back cushion (E2611) headrest, cushioned, any 
type, including fixed mounting hardware (E0955).