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 (tilt, 
recline, legrests), and upgraded electronics. We decided that the Plan does not have to pre-approve power 
seat elevator.  
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and accessories.. 
You say that this is medically necessary for the enrollee. The Plan says that the enrollee does not have a 
medical need for multiple power options. 
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options 
(tilt, recline, legrests), and upgraded electronics.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 (tilt, recline, legrests), and upgraded electronics. Our reviewer says that the requested 
Group 3 power wheelchair with multiple power options and upgraded electronics are not 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 upper extremity weakness and contracture of 
hand from a stroke. The enrollee cannot operate a power scooter due to impaired ability to transfers and 
impaired upper extremity strength. A power wheelchair is required for mobility and accomplishing daily 
activities. The enrollee has 2 out of 5 motor strength in the left upper and lower extremities with contracture. 
He cannot functionally perform weight shifts. Therefore, the enrollee requires a group 3 power wheelchair with 
power tilt and recline for pressure relief given the more complex seating needs. The enrollee requires power 
elevating leg rests for positioning of lower extremities with limited range of motion. The upgraded electronics 
are necessary to operate the Group 3 power wheelchair with its power components. Therefore, the reviewer 
found that a Group 3 power wheelchair with multiple power options (tilt, recline, legrests) and upgraded 
electronics are medically reasonable and necessary. 
  
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 (tilt, recline, legrests), 
and upgraded electronics have been met. Therefore, we decided that the Plan has to pre-approve a Group 3 
power wheelchair with multiple power options (tilt, recline, legrests), and upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve power seat elevator. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevator may be covered when certain 
criteria have been 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 power seat elevator. Our reviewer says 
that the requested Group 3 power wheelchair with multiple power options and upgraded electronics are not 
medically necessary. Our physician reviewer found the enrollee cannot functionally propel a manual 
wheelchair due to upper extremity weakness and contracture of the hand from a stroke. The reviewer found that 
the enrollee requires maximum assistance for transfers. A power seat elevator would not allow for independent 
transfers. Therefore, the reviewer found that the requested power seat elevator is not medically reasonable or 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve power seat elevator. 
 
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.