When considering a prior authorization request, DHS must consider medical necessity, appropriateness, cost, alternatives, and whether the service is an effective and appropriate use of available services. In this case, the petitioner requested prior authorization for a power wheelchair that had a power stand function. The requested wheelchair would have replaced the petitioner’s daily wheelchair that was covered by Medicare in the previous year. Although the standing feature would have increased independence and improved the petitioner’s health, ALJ Brian Schneider concluded the request was correctly denied because it was not cost effective to replace a wheelchair the petitioner received less than two years ago, and the petitioner had not had a major change of circumstances.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed November 14, 2025, under Wis. Stat., § 49.45(5), to review a decision by the Division of Medicaid Services (DMS) to deny Medical Assistance (MA) authorization for a power wheelchair with a standing feature, a hearing was held on February 11, 2026, by telephone. Hearings set for December 18, 2025 and January 20, 2026 were rescheduled at the petitioner’s request.
The issue for determination is whether the DMS correctly denied the requested equipment.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
201 E. Washington Ave.
Madison, WI 53703
By: Written submission of Julie Larson-Leverenz, OTR
Division of Medicaid Services
PO Box 309
Madison, WI 53701-0309
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a 41-year-old resident of Brown County who is eligible for MA.
- Petitioner is paraplegic without the use of his legs. He has spasticity in his legs, and recently he was diagnosed with osteoporosis with decreased bone density. He resides alone, and he has no paid caregivers.
- Until 2024 petitioner used a manual wheelchair with no tilt function for mobility. In February, 2024, he was provided a power wheelchair with tilt, recline, and elevating leg rests and seat, paid primarily by Medicare with MA covering the $1,157 not paid by Medicare.
- On June 30, 2025, — requested prior authorization for a new power wheelchair with tilt, recline, and elevating leg rests and seat, and in addition a power stand function at a cost of $154,003.96, PA no. 5251810025. The request noted that the standing feature would allow petitioner more independence with activities of daily living that involve heights, in particular cooking, cleaning, and self-care. It would help improve bone density, skin integrity, circulation, digestive health, and spasticity management.
- Medicare does not cover power standing systems. The requested chair is a “Group 4” chair, and Medicare does not cover Group 4 chairs. His current chair is a Group 3 chair, and thus it was covered by Medicare.
- By a letter dated August 19, 2025, the DMS denied the prior authorization request, concluding that he has a power wheelchair less than two years old, that there is no documentation of a significant change in condition warranting replacement of the current chair, and there was no evidence that other options have been tested as alternatives to the power stand feature.
Discussion
MA regulations require the Department to consider, among other things, the medical necessity of the service, the appropriateness of the service, the cost of the service, the extent to which less expensive alternative services are available, and whether the service is an effective and appropriate use of available services. Wis. Admin. Code, § DHS 107.02(3)(e)1.,2.,3.,6. and 7. “Medically necessary” means a medical assistance service under ch. DHS 107 that is:
- Required to prevent, identify or treat a recipient’s illness, injury or disability; and
- Meets the following standards:
- Is consistent with the recipient’s symptoms or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability;
- Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider, and the setting in which the service is provided;
- Is appropriate with regard to generally accepted standards of medical practice;
- Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient;
- Is of proven medical value or usefulness and, consistent with s. HFS 107.035, is not experimental in nature;
- Is not duplicative with respect to other services being provided to the recipient;
- Is not solely for the convenience of the recipient, the recipient’s family, or a provider;
- With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
- Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.
Wis. Admin. Code, § DHS 101.03(96m) It is the provider’s obligation to justify the provision of the requested service or equipment. Admin. Code, §DHS 107.02(3)(d)6.
The purpose of any durable medical equipment is to replace the functional ability that the person’s disability has taken away. A person receives a power wheelchair because he cannot move about without one. With the chair comes some degree of independence. If a person’s disability prevents him from not only moving about like his peers but also from adjusting to the various heights of tables and reaching for items like his peers, the same logic that justifies the wheelchair also justifies a standing feature that will allow him to function at a level closer to his peers. With it he could arguably access tables and countertops of various heights and potentially perform tasks that he could not perform from a seated position. The standing feature also allows him to put weight on his legs to help with circulation, bone/joint health, and management of contractures and spasticity. See MA Providers Manual, Topic 21137.
When the DMS received the prior authorization request, all of that was known to the DMS consultant. Nevertheless, the DMS denied the request. The problem for petitioner is that just one year prior, a request was made for a power wheelchair in which the provider would have attested that the requested chair met all of petitioner’s mobility and care needs. A wheelchair has a life expectancy of six years, so without some major change in the person’s functioning, the DMS is going to look askance at proving upgraded equipment so soon after providing an item that allegedly meets the person’s needs.
Petitioner noted that he has a new diagnosis of osteoporosis, but that is not a new condition. It is a name given to a condition petitioner already had. In this case I must acknowledge the Department’s expertise and understanding of the idea of cost effectiveness. The requesting provider did not make any assessment of alternative means to meet petitioner’s needs, and the provider did not assess alternative means of achieving the goals mentioned above.
I conclude that the DMS correctly denied the requested wheelchair that was requested soon after one was provided.
Conclusions of Law
The requested power wheelchair is not cost effective because a power wheelchair was purchased through public funds just fifteen months before this one was requested, and petitioner has not had a major change of circumstances necessitating the change.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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