Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) manual 
swingaway (E1028) power seating system, combination tilt and recline, with mechanical shear reduction 
(E1007) positioning wheelchair back cushion, planar back with lateral supports (E2620)  center mount power 
elevating leg rest/platform, complete system (E1012) cushioned headrest (E0955)  lateral thigh or knee support 
(E0953) expandable controller (E2377) harness (E2313) and electronic connection between wheelchair 
controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that you request 
that this request be reviewed, and that the denial be overturned. The Plan denied your request. The Plan says 
the requested Group 3 powered wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not 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 to pre-approve the power wheelchair and upgraded 
electronics. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that the enrollee's mobility deficit cannot be helped by the use of an ultralight weight manual 
wheelchair. The provided records document that the enrollee has 4/5 upper extremity strength and is modified 
independent with feeding, grooming and hygiene thus indicating the enrollee has adequate upper extremity 
strength and function to operate the wheelchair's power options with their own switches. Provided records do 
not document the enrollee has a musculoskeletal condition or the presence of a cast or brace which prevents 90-
degree flexion at the knee, or the enrollee has significant edema of the lower extremities that requires an 
elevating leg rest. Provided records do report a pressure ulcer which would qualify for power tilt/recline if the 
enrollee met criteria for the power wheelchair base. Provided records report the enrollee uses an ultralight 
weight manual wheelchair indoors and the power wheelchair has been for use outside the home, thus the power 
wheelchair base does not meet criteria for coverage based on the available records, per Local Coverage 
Determination (LCD) Power Mobility Devices L33789.  
 
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 power wheelchair and upgraded electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) manual 
swingaway (E1028) power seating system, combination tilt and recline, with mechanical shear reduction 
(E1007) positioning wheelchair back cushion, planar back with lateral supports (E2620)  center mount power 
elevating leg rest/platform, complete system (E1012) cushioned headrest (E0955)  lateral thigh or knee support 
(E0953) expandable controller (E2377) harness (E2313) and electronic connection between wheelchair 
controller and two or more power seating system motors (E2311).