Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) represented by 
code K0858, and related accessories represented by codes E1028, E2361, E2310, E1002, E0955, E1028, and 
E2608. 
 
You asked the Plan to pre-approve codes K0858, E1028, E2361, E2310, E1002, E0955, E1028, and E2608. 
You say that the enrollee needs the requested wheelchair due to immobility and being at significant risk for 
skin breakdown and injury due to falls with high fall and transfer risk. You say that the records provided 
support the medical necessity of the requested items. The Plan denied your request. The Plan says the criteria 
for coverage of the requested base PWC have not been met. The Plan says that the enrollee may meet the 
criteria for a simpler power wheelchair. 
 
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 codes K0858, E1028, E2361, E2310, 
E1002, E0955, E1028, and E2608. Our reviewer says that the requested items which remain in dispute are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 
Group 3 qualifying diagnosis of a neurological condition of multiple sclerosis. She also has a diagnosis of back 
pain.  The treating medical physician documentation is conflicting. The physician documentation states she is 
unable to use a cane. The physician documentation is not clear that she is unable to perform activities of daily 
living (ADLs) effectively with an appropriately fitted manual wheelchair.  The physician documentation 
review of systems states that the enrollee denies gait abnormality. The enrollee has back pain aggravated with 
walking. The documentation does not include a detailed neurological or musculoskeletal upper extremity and 
lower extremity examination supporting the need for power wheelchair or that the enrollee cannot effectively 
weight shift. The documentation indicates a seizure disorder with a visit to the emergency room on September 
8, 2022, for a breakthrough.  The documentation is not clear that the enrollee's seizure disorder has stabilized, 
and an active seizure disorder would not allow safe use of a power mobility device. The documentation does 
not reveal that the enrollee needs a power seating system. There is no evidence the enrollee uses a ventilator 
attached to a wheelchair, is at high risk for development of a pressure ulcer. There is no evidence of 
intermittent catheterization. The physician documentation does not indicate objective evidence of spasticity or 
increased tone on a lower extremity physical exam that needs a power seating system for management 
therefore the request exceeds the enrollee's medical needs. As the requested wheelchair and tilt feature are not 
medically necessary the related E1028, E2361, E2310, E1002, E0955, E1028, and E2608 are also not 
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 codes K0858, E1028, E2361, E2310, E1002, E0955, E1028, and E2608 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
(PWC) represented by code K0858, and related accessories represented by codes E1028, E2361, E2310, 
E1002, E0955, E1028, and E2608.