Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair and related accessories. We decided 
that the Plan does not have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with single power option (K0856) and 
related accessories, including a power seat elevation system.. You say that the requested power wheelchair is a 
medical necessity for the enrollee. The Plan says that the request is not medically necessary. 
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair and related accessories.  
 
The Plan follows Medicare rules. The rules say that a power wheelchair is covered if the criteria listed in the 
Medicare rules section of this letter have been met. 
 
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 and related 
accessories. Our reviewer says that the requested power wheelchair and related accessories are medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee requires a Group 3 power 
wheelchair for mobility and accomplishing daily activities given the enrollee's neurological condition (right 
sided internal carotid artery stroke). The enrollee is dependent for transfers and performing all her daily 
activities and cannot independently perform pressure relief given left upper extremity weakness. The enrollee is 
at risk of skin breakdown. Therefore, the enrollee requires a power wheelchair power tilt and recline as well as 
a power articulating platform for positioning of lower extremities along with adequate pressure relief. The 
requested group 3 power wheelchair and accessories, including power tilt and recline and power articulating 
foot platform, are medically 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 a Group 3 power wheelchair and related accessories have been met. Therefore, 
we decided that the Plan has to pre-approve a Group 3 power wheelchair and related accessories.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system. 
 
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.