Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the Group 3 power wheelchair and the upgraded electronics 
represented by codes E2361, E2607, E2620, E0955, and E0956. We decided that the Plan does not have to pre-
approve the upgraded electronics represented by codes E1002, E1012, E2311, K0040, E1028, and K0108.  
 
You asked the Plan to pre-approve the Group 3 power wheelchair and the upgraded electronics represented by 
codes E2361, E2607, E2620, E0955, E0956, E1002, E1012, E2311, K0040, E1028, and K0108. You say that 
the medical records provided support the need for the requested wheelchair and accessories. The Plan says that 
the enrollee does not have a medical need for a single power option that would be included with a group 3 
power wheelchair. The Plan says that the requested accessories are not medically necessary. 
 
 
 
We decided that the Plan has to pre-approve the Group 3 power wheelchair and the upgraded electronics 
represented by codes E2361, E2607, E2620, E0955, and E0956.  
 
The Plan follows Medicare rules. Medicare rules say that Group 3 power wheelchairs and accessories are 
covered for certain indications and when medically necessary. 
 
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 Group 3 power wheelchair and the 
upgraded electronics represented by codes E2361, E2607, E2620, E0955, and E0956. Our reviewer says that 
the criteria for coverage of these items have been met. Our physician reviewer found that the enrollee has a 
personal mobility deficit that impairs his participation in mobility related activities of daily living. It is 
documented that the enrollee does not have sufficient upper extremity strength to self-propel a manual 
wheelchair. The enrollee has a congenital skeletal deformity called spina bifida. Our physician reviewer also 
found that up to 2 batteries at any one time are allowed if required for a power wheelchair. A skin protection 
and positioning wheelchair seat cushion, a positioning wheelchair back cushion, a cushioned head rest, and a 
lateral trunk or hip support would be considered 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 the Group 3 power wheelchair and the upgraded electronics represented by 
codes E2361, E2607, E2620, E0955, and E0956 have been met. Therefore, we decided that the Plan has to pre-
approve the Group 3 power wheelchair and the upgraded electronics represented by codes E2361, E2607, 
E2620, E0955, and E0956.  
 
We also decided that the Plan does not have to pre-approve the upgraded electronics represented by codes 
E1002, E1012, E2311, K0040, E1028, and K0108. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. 
 
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 upgraded electronics represented by 
codes E1002, E1012, E2311, K0040, E1028, and K0108. Our reviewer says that the criteria for coverage of 
these items have not been met. Our physician reviewer found the documentation does not support that the 
enrollee is at high risk for development of a pressure ulcer, is unable to perform a functional weight shift, 
utilizes intermittent catheterization for bladder management, is unable to independently transfer from the 
wheelchair to the bed, or needs a power seating system to manage increased ton or spasticity. An electronic 
connection between the wheelchair controller and two or more power seating system motors is not covered 
because the sole function of the connection is for a power seat elevation or power standing feature. Adjustable 
angle footplates are only separately payable when provide with leg rests coded as E1012. The documentation 
does not support the medical necessity of a manual swingaway, retractable or removable mounting hardware 
for a joystick. The documentation dos not support the medical necessity of the wheelchair component or 
accessory that was not specified and represented by code K0108. 
 
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 upgraded electronics represented by codes E1002, E1012, E2311, K0040, 
E1028, and K0108 have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
upgraded electronics represented by codes E1002, E1012, E2311, K0040, E1028, and K0108.