Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 standard power wheelchair (K0823) and additional items 
and accessories (codes E1028, E0973 x2, and E2365). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that this enrollee does not live in a SNF, but resides in an assisted living facility with the same 
National Provider Identifier (NPI) as the SNF. You also say that you would like this request to be reviewed and 
the denial to be overturned. The Plan denied your request. The Plan says that this request is not a covered 
benefit per Medicare guidelines because the patient's home is considered a skilled nursing facility (SNF). The 
Plan also says that a patient in a skilled nursing facility is not entitled to have separate Part B payment made for 
the rental or purchase of durable medical equipment. 
 
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 wheelchair 
and additional items and accessories. Our reviewer says that the group 2 power wheelchair is medically 
necessary. Our physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for 
mobility. The enrollee cannot functionally propel a manual wheelchair due to lack of upper extremity 
endurance, shortness of breath, and impaired shoulder range of motion. Our reviewer found that the enrollee 
cannot operate a power scooter due to impaired ability to transfer. They require a power wheelchair for 
mobility and accomplishing their daily activities. The enrollee resides in a long-term care facility and their 
current power wheelchair is no longer functional and repairable and is greater than 5 years of age. It requires 
replacement. Our physician reviewer also found that the enrollee has been evaluated for a power wheelchair 
and can operate 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 wheelchair and additional items and accessories have 
been met. Specifically, we did not base our decision on the rule used by the Plan, as the records provided do 
not show that the facility where the enrollee resides is a SNF, but rather it is an Assisted Living Facility. 
Therefore, we decided that the Plan has to pre-approve a group 2 standard power wheelchair (K0823) and 
additional items and accessories (codes E1028, E0973 x2, and E2365).  
 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.