Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair, power tilt, and other 
accessories (K0856, E0955, E1002, E1028, E2361, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has left sided 
hemiplegia and hemiparesis due to a stroke making her a substantial risk for injuries related to falls. She is a 
heightened risk for developing pressure injuries from prolonged sitting due to her inability to redistribute 
weight or perform functional weight shift due to right upper extremity strength 2-/5. The wheelchair and 
accessories are medically necessary. The Plan denied your request. The Plan says the enrollee is ambulatory 
becoming more mobile and managing at home independently. The enrollee does not have a medical need for a 
single power option (power tilt) included with a group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
mobility deficit. The documentation is conflicting that the deficit significantly impairs MRADL performance as 
the physician document states that the enrollee is ambulatory, more mobile, and managing independently at 
home. The documentation indicates the enrollee has some unsteadiness with a cane. The enrollee is unable to 
use a manual wheelchair due to hemiplegia of the left arm per documentation, but the documentation is not 
clear that the enrollee is unable to use a modified manual wheelchair for a hemiplegic enrollee. The enrollee is 
not at high risk of developing a pressure ulcer, does not have spasticity or use intermittent catheterization 
therefore the request for power tilt exceeds her needs. The documentation does not support that the enrollee 
requires the requested group 3 power wheelchair with power tilt and accessories as this appears to exceed her 
needs per Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Section 280.3(B) and  per Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. 
 
 
 
 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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair, power tilt, and other accessories 
(K0856, E0955, E1002, E1028, E2361, E2607).