Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Group 3 power wheelchair (PWC) with multiple power options and accessories.
You asked the Plan to provide coverage for this equipment. You say that at the time of the appeal, this equipment was medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file at the reopen request. At issue is coverage for a group 3 power wheelchair (PWC) with multiple power options and accessories. The Maximus Physician Reviewer determined that the enrollee is at high risk for skin break down based on history of skin breakdown, habitus, severity of quadriplegia, presence of skin disease, and incontinence. Therefore, it was decided that the Plan had to pre-approve a group 3 power wheelchair (K0861). It was determined that the E2311 Electronic connection, E2377 Expandable Controller, and E2313 Expandable Controller Harness are not covered, as the documentation does not establish that it is medically necessary for the enrollee to control the three requested power options through the joystick (drive interface). The medical records by the enrollee's provider do not provide sufficient support the medical necessity of the requested items. It was also decided that the plan did not have to approve multiple power options and accessories (E2361, E1028, E1007, E0955, E1028, E1012, E1028, E0956, E2377, E2313, E2311, E2603, E2620). The Plan requested a reopen and noted the enrollee was explicitly stated to be at moderate risk for development of pressure ulcer. The member does not have medical need for the Multiple Power Options included with the requested K0861 group 3 power wheelchair with Multiple Power Options. To qualify for the requested group 3 power wheelchair with multiple power options, there must be medical need for a ventilator or for two power options: power tilt and power recline. Documentation does not show that member is at "High Risk" for skin breakdown. No self-catheterization or spasticity. The enrollee is not on anti-spasmodics and is documented to have Hypotonicity. The enrollee's medical history includes obesity, diabetes, hypertension, bullous pemphigoid, and inclusion body myositis resulting in quadriplegia. The enrollee is bed-ridden and incontinent.
A history of skin issues on his lower thigh and buttocks is documented in October 2022, and the enrollee had redness on his sacrum in December 2022. The Braden Scale Score placed him at moderate risk. The Plan is correct in this case. The documentation is insufficient to support that the coverage criteria for a group 3 power wheelchair K0861 with multiple power options and accessories were met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to provide coverage for Group 3 power wheelchair (PWC) with multiple power options and accessories.