Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt, recline, ) and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee is recovering from bed sores. The 
Plan denied your request. The Plan says the notes do not show a medical need for multiple power options 
included with the K0861 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 the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
physician exam notes do not indicate a history of sacral pressure ulcers, flap surgery, or current sacral pressure 
sores that require power seating. Physician notes do not indicate a history of intermittent catheterization. 
Physician notes do not indicate that the enrollee is taking anti-spasticity medications. The physician exam 
states there is significant spasticity in all limbs. The documentation notes that the enrollee lives in "a senior 
living facility" but does not include details of this facility with objective measurements of the home indicating 
there is adequate access between rooms, maneuvering space, and surfaces for the operation of the power 
wheelchair. The documentation is not clear that the power wheelchair will significantly improve MRADL 
participation. The documentation indicates there is concern for glaucoma and that the patient was due for an 
eye exam. The documentation does not reveal results of this eye exam supporting that the enrollee has adequate 
vision for operating a power wheelchair safely. Furthermore, the physician documentation indicates that the 
enrollee suspects underlying dementia and a magnetic resonance imaging (MRI) was ordered to rule out a 
stroke or tumor. The results of this workup and MRI are not clear. The etiology of the enrollee's recent 
increased cognitive decline is not fully worked up. The documentation indicates that the enrollee is not oriented 
to time and had short term memory deficits therefore the documentation is conflicting that the enrollee has the 
cognitive ability to manage this wheelchair safely. The documentation does not fully support that the enrollee 
could recall and retain instructions on how to safely operate this K0861 wheelchair and accessory controls.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair with multiple power options (tilt, recline, ) and accessories.