The Administrative Law Judge (ALJ) issued a decision dated April 13, 2001. The appellant has asked the Medicare Appeals Council to review this action. The Council grants the request for review because the action, findings or conclusions of the ALJ are not supported by substantial evidence. See 20 C.F.R. �� 404.967 and 404.970, incorporated by reference in 42 C.F.R. � 405.856.

Because this decision is fully favorable to the appellant and all other parties, the Council has not issued a separate notice granting the request for review.

Procedural and Factual History

The beneficiary received a power-operated wheelchair and accessories from the appellant on December 9, 1997. Exh. 1, pages 3-7. At that time, the beneficiary was an elderly female with cellulitis of both lower extremities, chronic obstructive pulmonary disease, diabetes mellitus, severe peripheral vascular disease, coronary artery disease, arthritis, edema and significant obesity. Exh. 1, pages 1, 2, 8, 10 and 13. On October 5, 1997, the beneficiary experienced syncope of an unknown origin and had a fall which required hospitalization. Exh. 1, pages 10-13. The hospital records state that the beneficiary was largely bed and wheelchair-bound, and was unable to walk. Id. After her discharge from the hospital, the beneficiary's physician followed-up and prescribed a power-operated wheelchair. Exh. 1, page 2; Exh. 6

The Medicare DMERC ⁽¹⁾, CIGNA, originally allowed payment, but later conducted a postpayment review. Exh. 7 at 3. CIGNA reopened the original allowance and denied coverage of the power-operated wheelchair and accessories. Exhs. 3 and 4. The appellant requested a Fair Hearing Officer hearing and decision. A telephone hearing was held, and the Fair Hearing Officer issued a decision on May 26, 2000, which denied coverage of the power-operated wheelchair and accessories, finding that the documentation provided by the supplier/appellant was not sufficient to support a determination that the items were medically reasonable and necessary. Exh. 7.

The appellant requested a hearing with an ALJ. Exh. 8. The ALJ held a hearing on May 31, 2000, and issued a decision on April 13, 2001. Dec. at 1. In his decision, the ALJ found that there was insufficient medical documentation to support a determination that the power-operated wheelchair and accessories were medically reasonable and necessary, and therefore, held that Medicare coverage and payment for the items was not warranted. Dec. at 5.

The appellant filed a timely request for Medicare Appeals Council Review. Therefore, the matter is currently before the Council and ripe for adjudication.

Discussion

The central issue in this case is whether the documentation provided by the appellant supplier of the power-operated wheelchair and accessories in question is sufficient to support a determination that the power-operated wheelchair and accessories were medically reasonable and necessary for the beneficiary when supplied. Section 1862(a)(1)(A) of the Social Security Act (the Act) provides that:

[N]o payment may be made under part A or part B for any expenses incurred for items or services which ... are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

The ALJ decision cited DMERC issuances referenced in the Fair Hearing Officer Decision as supporting the determination that there was not sufficient documentation to prove that the power-operated wheelchair supplied was medically reasonable and necessary.

In reviewing the applicable statutes, regulations, manual sections, DMERC issuances, and national coverage determinations, the Council finds that there was ample medical evidence in the file to support a finding that the power-operated wheelchair was medically reasonable and necessary for the beneficiary.

National Coverage Determination (NCD) 60-9, which is binding on the DMERC and the ALJ, provides that a wheelchair is covered if the beneficiary's condition is such that without the use of a wheelchair she would otherwise be bed or chair confined. NCD 60-9 further provides that a power operated wheelchair is covered if a wheelchair is medically necessary and the beneficiary is unable to operate a wheelchair manually. The ALJ cited DMERC manual provisions concerning documentation of medical necessity, but did not expressly evaluate this claim under the criteria set forth in NCD 60-9. We find that the evidence unequivocally demonstrates that the beneficiary needed a power wheelchair under these criteria.

Specifically, the file contains the following:

1.) A valid Certificate of Medical Necessity which is signed and dated by the treating physician and contains the physician's address, phone number and UPIN ⁽²⁾ as well as the beneficiary's conditions and diagnosis and a realistic estimate of the total length of time the equipment would be needed. Exh. 1, page 1.

2.) A physician's order for a power wheelchair which is signed and dated by the treating physician and contains the physician's address, phone number and UPIN as well as the beneficiary's conditions and diagnosis and a a statement regarding medical reasonableness and necessity. Exh. 1, page 2.

3.) Hospital records from Lakewood Regional Medical Center which document the beneficiary's admission on October 5, 1997, and which substantiate the beneficiary's need for a power-operated wheelchair because she is bed or chair confined, and can not ambulate. These treatment records corroborate the physician's statem ents regarding the beneficiary's conditions and diagnoses. Exh. 1, pages 10-13.

All of these documents were created prior to or contemporaneous with the provision of the power-operated wheelchair and accessories, and therefore, provide credible evidence of medical reasonableness and necessity. In addition, the physician later explained that the beneficiary was unable to operate a manual wheelchair because of chronic obstructive pulmonary disease, heart disease, lumbar spine disease, and obesity, all of which are documented in the treatment records. Exhs. 6 and 10.

We note that the record reflects that the carrier paid another supplier paid for maintenance and servicing on a manual wheelchair (code K0001) on January 21, 1998. Exhs. 3 and 5. The manual wheelchair was apparently not used in the beneficiary's home after she received the power wheelchair, but rather, was used for someone to push her in order to go to doctor's appointments because the power wheelchair was too heavy to be lifted into the car. Exh. 5. This evidence does not disprove that a power wheelchair was needed and used within the home. Subject to the rules on administrative finality, the carrier may consider whether payment for the manual wheelchair was appropriate if it is used only outside the home.

After careful consideration of the entire record, the Medicare Appeals Council makes the following findings:

1. The Appellant provided a power-operated wheelchair and accessories to the beneficiary on December 9, 1997.

2. The administrative record contains sufficient medical documentation to prove that the beneficiary's condition is such that without the use of a wheelchair she would otherwise be bed or chair confined, and that the beneficiary is unable to operate a wheelchair manually.

3. The power-operated wheelchair and accessories provided to the beneficiary by the Appellant were medically reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

DECISION

It is the decision of the Medicare Appeals Council that the power-operated wheelchair and accessories at issue are Medicare covered items because the medical documentation provided proves that the items were medically reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

Date: September 27, 2004

Clausen J. Krzywicki
Administrative Appeals Judge

Bruce P. Gipe
Administrative Appeals Judge

1. DMERC stands for "Durable Medical Equipment Regional Carrier."

2. The UPIN is the physician's Unique Physician Identification Number as assigned by the Centers for Medicare and Medicaid Services [(CMS) - formerly the Health Care Financing Administration (HCFA)].