Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861),
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial
issue (CPT code E2377), harness for upgrade to expandable controller (CPT code E2313), manual swing away,
retractable or removable mounting hardware for joystick (CPT code E1028), power seating system,
combination tilt and recline (CPT code E1007), headrest (CPT code E0955), addition to power seating system,
center mount power elevating leg rest/platform (CPT code E1012), 22nf sealed lead acid battery (CPT code
E2361), specialty joystick handle for hand control interface (CPT code E2323) and seat cushion (CPT code
E2601), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the enrollee meets criteria for a Group 3 power wheelchair without Power Options,
however the enrollee does not meet criteria for tilt and recline features and therefore does not meet criteria for
the requested base code K0861 Group 3 power wheelchair with Multiple Power Options.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The request for power wheelchair
cannot be covered. Per Medicare rules, the requested power wheelchair (Group 3 Power Wheelchair with
Multiple Power Options) is medically necessary when a person has need for power tilt and power recline. The
notes do not show that the enrollee has a medical need for these power options. Upgraded electronics
(expandable controller, harness and electronics) cannot be covered per Medicare rules. There is not a medical
need to control more than two power options though the joystick. The headrest is not needed without power tilt
and recline. The denial is upheld. A request for a power wheelchair that meets the enrollee's needs and
Medicare guidelines (Group 3 power wheelchair without power options) can be reviewed if submitted. More
information will be given to your provider. Therefore, we decided that the Plan does not have to pre-approve
power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to
and including 300 pounds (CPT code K0861), expandable controller, including all related electronics and
mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable
controller (CPT code E2313), manual swing away, retractable or removable mounting hardware for joystick
(CPT code E1028), power seating system, combination tilt and recline (CPT code E1007), headrest (CPT code
E0955), addition to power seating system, center mount power elevating leg rest/platform (CPT code E1012),
22nf sealed lead acid battery (CPT code E2361), specialty joystick handle for hand control interface (CPT code
E2323) and seat cushion (CPT code E2601), for the enrollee.