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 (K0861) and accessories.

You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (K0861) and accessories. You say that the requested group 3 power wheelchair with multiple power options and accessories is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested group 3 power wheelchair with multiple power options and accessories.

The Plan must follow 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 a group 3 power wheelchair with multiple power options (K0861) and accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair with multiple power options and accessories. Our physician reviewer found the requested Group 3 power wheelchair with multiple power options is not medically necessary per the Local Coverage Determination (LCD) Power Mobility Devices (L33789). The documentation notes the enrollee has a mobility deficit that interferes with mobility related activities of daily living (MRADLs) in the home. The documentation notes the mobility deficit cannot be effectively overcome with an assistive device due to poor endurance, weakness and fall risk. While the enrollee is noted safe to operate the requested device the documentation does not support that this Group 3 power wheelchair is medically necessary. The enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or clear evidence of being high risk for a pressure ulcer. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the right upper extremity supports that the enrollee can control any power options through their own individual switches. Therefore the request for a Group 3 power wheelchair with multiple power options is not medically necessary per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) and Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system. Additionally, per Local Coverage Determination (LCD): Wheelchair Seating (L3312) a headrest (E0955) as the enrollee's power tilt and/or recline power seating system is not medically necessary the E0995 criteria have not been met.

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 (K0861) and accessories 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 (K0861) and accessories.