Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 2 standard power operated vehicle (K0823), wheelchair 
access manual swing away other controls (E0128), two U1 batteries installed (E2365 x2), two flip up height 
adjustable arm rests (E0973 x2), and mold new chair labor (K0739 x5). We decided that the Plan does not have 
to pre-approve a tie down kit and accessories (K0108).  
 
You asked the Plan to pre-approve a Group 2 standard power operated vehicle (K0823), wheelchair access 
manual swing away other controls (E0128), two U1 batteries installed (E2365 x2), two flip up height adjustable 
arm rests (E0973 x2), tie down kit and accessories (K0108), and mold new chair labor (K0739 x5). You say 
that you live in a 300-foot-long apartment building and used to have a side entrance, but the building blocked it 
due to troubles in the building, and now you have to go over 300 feet around just to get to the door. You also 
say that you can walk about 75 feet but then have to sit and rest, because your knees are weak. The Plan says 
that there is no supporting documentation indicating medical necessity and there is no direct observation of 
your functional issues. The Plan also says there is no documentation of any injury and/or harm related to your 
reported symptoms and no direct documentation and/or explanation from your provider indicating that the 
request is medically necessary. 
 
We decided that the Plan has to pre-approve a Group 2 standard power operated vehicle (K0823), 
wheelchair access manual swing away other controls (E0128), two U1 batteries installed (E2365 x2), two 
flip up height adjustable arm rests (E0973 x2), and mold new chair labor (K0739 x5).  
 
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 a Group 2 standard power operated 
vehicle (K0823), wheelchair access manual swing away other controls (E0128), two U1 batteries installed 
(E2365 x2), two flip up height adjustable arm rests (E0973 x2), and mold new chair labor (K0739 x5). Our 
reviewer says that the Group 2 power wheelchair and accessories are medically necessary. Our physician 
reviewer found you are functionally non-ambulatory and cannot use a cane or walker for mobility. You cannot 
functionally propel a manual wheelchair due to upper extremity weakness and lack of endurance from 
congestive heart failure. Our reviewer found that you cannot use a power scooter since your home is not 
accessible. You require a power wheelchair for mobility and accomplishing your daily activities. Our physician 
reviewer also found that you have been evaluated for the power wheelchair as well as your home for 
accessibility and can safely use it.  
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 standard power operated vehicle (K0823), wheelchair access manual 
swing away other controls (E0128), two U1 batteries installed (E2365 x2), two flip up height adjustable arm 
rests (E0973 x2), and mold new chair labor (K0739 x5) have been met. Therefore, we decided that the Plan has 
to pre-approve a Group 2 standard power operated vehicle (K0823), wheelchair access manual swing away 
other controls (E0128), two U1 batteries installed (E2365 x2), two flip up height adjustable arm rests (E0973 
x2), and mold new chair labor (K0739 x5).  
 
We also decided that the Plan does not have to pre-approve a tie down kit and accessories (K0108). 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The tie down kit and accessories (K0108) is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve a tie down kit and accessories (K0108). 
 
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.