Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Big Bounder 1000 power wheelchair and accessories.

You asked the Plan to pre-approve the Big Bounder 1000 power wheelchair and accessories. You say that this
specific chair is medically necessary for the enrollee. The Plan denied your request. The Plan says that the
home evaluation was not complete. The Plan also states that the requested chair (coded with K0899) has not
been reviewed by the Pricing, Data, Analysis, and Coding (PDAC) contractor.

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 patient's 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 Big Bounder 1000 power
wheelchair and accessories. Our reviewer says that this patient meets criteria for a power wheelchair. Our
physician reviewer found the enrollee is a 42-year-old man with severe morbid obesity, arthritis and back pain.
The enrollee has been treated for cellulitis of his left lower limb and a cutaneous abscess of his abdominal wall.
It is noted that the enrollee is having a great deal of difficulty getting into his wheelchair and getting around the
house. The enrollee is independent with bed to wheelchair, and wheelchair to commode transfers. It is noted
that the enrollee's strength, and range of motion is not sufficient for use of a manual wheelchair. The enrollee
has 3+/5 strength in his shoulders and elbows, and 4/5 strength in his hands and wrists. A mobility assessment
was done on 6/3/21. This assessment shows that the enrollee has a personal mobility deficit that impairs
participation in activities of daily living. In addition, the enrollee is unable to use a walker or can and he does
not have sufficient upper extremity strength to use a manual wheelchair give his severe morbid obesity. There
is also evidence that the enrollee can safely operate the requested power wheelchair.

In addition to the foregoing medical review, we do not find the Plan's argument regarding the coding of this
item to be persuasive. Our research finds that the correct code for the Big Bounder 1000 power wheelchair is
K0840, not K0899 as the Plan states. Therefore, the Plan's argument with regard to the lack of PDAC review
is inappropriate. In addition, beyond the arguments laid out above, the Plan has not provided any further
argument for non-coverage of the requested accessories. Because the Plan has made no such argument, we find
that a denial of these accessories is not appropriate either. 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 Big Bounder
1000 power wheelchair and accessories have been met. Therefore, we decided that the Plan has to pre-approve
a Big Bounder 1000 power wheelchair and accessories.

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.