Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to pre-approve a gel armpad, calf panel, tapered footplate cover, footplate bracket 
assembly, joystick mounting bracket, gatlin mounting bracket, and switch lights for a power wheelchair. You 
say that you are appealing with supporting records. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve gel armpad, calf panel, tapered footplate cover, footplate 
bracket assembly, joystick mounting bracket, and gatlin mounting bracket. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 wheelchair components. Our reviewer 
says that these components are medically necessary. Our physician reviewer found the enrollee is non-
ambulatory and requires a power wheelchair for mobility and performing daily activities. The enrollee cannot 
perform pressure relief independently due to upper extremity weakness and require a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. There is a history of skin breakdown. The 
enrollee is noted to have contractures of the upper and lower extremities with quadriplegia. The enrollee 
requires gel arm pads, a calf panel, a tapered footplate cover, and bracket assembly to support extremities and 
prevent skin breakdown. The power wheelchair also requires a gatlin mounting bracket and joystick mounting 
bracket to attach the necessary components. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these components have been met. Therefore, we decided that the Plan has to 
pre-approve wheelchair components.  
 
We also decided that the Plan does not have to pre-approve switch lights. 
 
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 switch lights. Our reviewer says that 
switch lights are not medically necessary. Our physician reviewer found that switch lights are not primarily 
medical in nature and therefore not 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 switch lights have not been met. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair components. 
 
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.