Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options and 
accessories. We decided that the Plan does not have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories 
(K0861, E2361, E2377, E2313, E1028, E1007, K0108, E2620, E0955, K0040, E2311, E0956, E2607) and a 
power seat elevation system (E2300). You say that the services are necessary. The Plan says that based on the 
documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options 
and accessories.  
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the services are medically necessary. Our 
physician reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or walker for 
mobility. He requires considerable assistance with ambulation is at high risk for falling. He cannot functionally 
propel a manual wheelchair due to upper extremity ataxia and impaired coordination. The patient cannot 
operate a power scooter due to impaired sitting balance and he requires assistance for transfers. He requires a 
power wheelchair for mobility and accomplishing his daily activities. He requires a group 3 power wheelchair 
with power tilt and recline given his significant ataxia, which impacts his trunk and extremities. He cannot 
independently maintain a seated position and therefore cannot use a group 2 power wheelchair. He requires the 
advanced seating of a group 3 power wheelchair. He cannot also functionally perform pressure relief and 
therefore requires the power tilt and recline.  
 
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 3 power wheelchair with multiple power options and accessories have 
been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with multiple 
power options and accessories.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met.  
 
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 power seat elevation system. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found he does not require 
the power seat elevator since he is noted to be unsafe with transfers and this would not allow him to be 
independent with transfers. 
 
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 power seat elevation system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power seat elevation system. 
 
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.