Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair (K0861). We decided that the Plan 
does not have to pre-approve multiple power options and accessories (E2361, E1028, E1007, E0955, E1028, 
E1012, E1028, E0956, E2377, E2313, E2311, E2603, E2620).  
 
You asked the Plan to pre-approve a group 3 power wheelchair (K0861) with multiple power options and 
accessories (E2361, E1028, E1007, E0955, E1028, E1012, E1028, E0956, E2377, E2313, E2311, E2603, 
E2620).. You say that the DME is medically necessary. The Plan says that the DME is not medically necessary. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair (K0861).  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 the wheelchair. Our physician reviewer found the 
enrollee is at high risk for skin break down based on history of skin breakdown, habitus, severity of 
quadriplegia, presence of skin disease, incontinence.  
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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
a group 3 power wheelchair (K0861).  
 
We also decided that the Plan does not have to pre-approve multiple power options and accessories). 
 
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 multiple power options and accessories. 
Our physician reviewer found the E2311 Electronic connection, E2377 Expandable Controller, and E2313 
Expandable Controller Harness are not covered, as the documentation does not establish that it is medically 
necessary for the enrollee to control the three requested power options through the joystick (drive interface). 
The medical records by the enrollees provider do not provide sufficient support the medical necessity of the 
requested items.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple power options and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve multiple power options and accessories (E2361, E1028, 
E1007, E0955, E1028, E1012, E1028, E0956, E2377, E2313, E2311, E2603, E2620). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.