Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement cover for wheelchair seat cushion or back cushion 
(E2619), support pads (K0108 x2), mesh covers for pads (K0108 x2), thigh hip supports (K0108 x2), and 
stealth gel pads, wide footplates (K0108 x2). 
 
You asked the Plan to pre-approve a replacement cover for wheelchair seat cushion or back cushion, support 
pads, mesh covers for pads, thigh hip supports, and stealth gel pads, wide footplates. You say that you trust the 
provided documentation is sufficient to approve the equipment that provides a disabled patient with their only 
means of independence. The Plan denied your request. The Plan says that the cushion cover, support pad and 
cover are already included with the approved cushion, and cannot be requested separately. The thigh supports 
are not properly coded and cannot be covered. The Plan also says gel pads do not serve a medical purpose and 
cannot be covered. 
 
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 a replacement cover for wheelchair seat 
cushion or back cushion, support pads, mesh covers for pads, thigh hip supports, and stealth gel pads, wide 
footplates. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is noted to have paraplegia and requires a 
power wheelchair for mobility and accomplishing daily activities. The requested power wheelchair repairs and 
replacement parts are medically appropriate. Our reviewer found that the requested replacement parts are 
consistent with normal wear and tear when using a power wheelchair and the components and repairs are 
required to keep the power wheelchair operational. The requested components are medical in nature and 
appropriate for the patient's condition. Our physician reviewer also found that the repairs and parts are less 
costly than replacing the power wheelchair. 
 
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 replacement cover for wheelchair seat cushion or back cushion, support pads, 
mesh covers for pads, thigh hip supports, and stealth gel pads, wide footplates have been met. Therefore, we 
decided that the Plan has to pre-approve a replacement cover for wheelchair seat cushion or back cushion 
(E2619), support pads (K0108 x2), mesh covers for pads (K0108 x2), thigh hip supports (K0108 x2), and 
stealth gel pads, wide footplates (K0108 x2).  
 
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.