Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0859) and accessories 
(E2363, E1028, E2323, E1002, E2311, and E1012). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair (K0859) and accessories (E2363, E1028, E2323, E1002, E2311, and E1012) are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested group 3 power wheelchair (K0859) and accessories (E2363, E1028, E2323, E1002, E2311, and 
E1012). 
 
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 and 
accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power 
wheelchair (K0859) and accessories (E2363, E1028, E2323, E1002, E2311, and E1012). Our physician 
reviewer found the requested group 3 power wheelchair (K0859) and accessories (E2363, E1028, E2323, 
E1002, E2311, and E1012) are not medically necessary per Local Coverage Determination (LCD): Wheelchair 
Options/Accessories (L33792) and Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
The enrollee's mobility deficit is not due to a Group 3 qualifying diagnosis. A November 15, 2021, wheelchair 
clinic note states that the enrollee has mobility limitations due to knee pain, lymphedema, and body habitus. 
The documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily 
living (MRADLs) in the home. The documentation indicates that the enrollee uses a rollator to participate in 
activities of daily living (ADLs) but is not a safe ambulator and needs to perform ADLs seated on rollator due 
to limited standing tolerance. The document states the enrollee is unable to use a walker, manual wheelchair or 
cane due to weakness, shoulder issues and safety/balances issues. The documentation does not reveal that the 
enrollee uses a ventilator attached to a wheelchair. The documentation reveals no evidence of intermittent 
catheterization. The documentation does not indicate that the enrollee is at high risk for development of a 
pressure ulcer. There is no history of prior pressure ulcer or flap surgery. The enrollee is modified independent 
in ambulation. The physician documentation does not indicate objective evidence of spasticity on a bilateral 
lower extremity (BLE) physical exam that needs a power seating system for management. The criteria for 
power tilt or recline have not been met. The Group 3 power wheelchair and accessories are not medically 
necessary and exceeds the enrollee's medical needs. 
 
 
 
 
 
 
 
 
 
 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 accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0859) and accessories 
(E2363, E1028, E2323, E1002, E2311, and E1012).