Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with electronic 
connection (E2311), expandable controller (E2377), and Expandable controller harness (E2313). 
 
You asked the Plan to pre-approve the Group 3 power wheelchair with multiple power options and expanded 
controller.. You say that this specific chair is medically necessary. The Plan denied your request. The Plan says 
this is not medically necessary. A Group 3 Power Wheelchair with no power options will be considered by the 
Plan if requested. 
 
The Plan follows Medicare rules. Medicare rules say that Group 3 Power Wheelchairs with multiple power 
options are only covered when specific criteria are met and the patient requires multiple power options and 
meets criteria for each of the requested options. 
 
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 the Group 3 power wheelchair with 
multiple power options and expanded controller. Our reviewer says that the requested Group 3 power 
wheelchair with multiple power options and expanded controller is not medically necessary. Our physician 
reviewer found that while the patient may be able to safely operate a power mobility device, the requested 
K0861 with multiple power options exceeds the patient's medical need. The patient does have a Group 3 
qualifying neurologic diagnosis, but the documentation does not reveal that the patient needs is at high risk for 
development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power 
seating system to manage increased tone or spasticity. Therefore, the request for power and tilt exceeds the 
patient's medical needs, as Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. The patient does not require non-proportional input devices (e.g., sip and puff, head array, etc.).The 
patient does not require 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 documentation does not support that it is medically necessary to control the requested power 
options through the joystick (drive interface). The patient's upper extremity strength and functional ability as 
evidenced by being set up for feeding should be sufficient to control any power options through their own 
switches. The documentation does not reveal that the E2377 Expandable Controller, E2313 Expandable 
Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are medically necessary 
per Local Coverage Article:  Wheelchair Options/Accessories - Policy Article (A52504). 
  
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 Group 3 power wheelchair with multiple power options and expanded 
controller. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair (K0861) with electronic connection (E2311), expandable controller (E2377), and 
Expandable controller harness (E2313).