Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options (K0861) 
with accessories/seating 
 
You asked the Plan to pre-approve the services. You say that the need for tilt and recline is clearly documented 
and the enrollee meets Medicare criteria. The Plan denied your request. The Plan says that the enrollee does not 
require the requested power options and a Group 3 power wheelchair with no power options could meet the 
enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 services. Our reviewer says that the 
requested wheelchair is medically reasonable and necessary. Our physician reviewer found that a mobility 
evaluation was performed on 6/9/22 which indicated that the patient spends most of her day in a recliner due to 
an inability to functionally ambulate. She currently uses a wheeled walker for mobility but has had multiple 
falls. She has 2-3/5 motor strength in the upper extremities and 3/5 motor strength in the lower extremities. She 
has impaired sitting balance and requires assistance for most of her daily activities as well as transfers and walking. She requires major help with transfers and is dependent for bathing. A home accessibility evaluation 
was performed. The patient has a progressive neurological disorder that impairs her mobility and ability to 
perform daily activities. She has impaired upper and lower body strength. She also suffers from chronic 
respiratory failure. She cannot safely use a cane or walker for mobility given her decreased strength, frequent 
falls, and compromised endurance. She also does not have the appropriate upper extremity strength and 
endurance to propel a manual wheelchair and does not have the upper extremity strength, trunk control and 
ability to independently transfer to use a power scooter. She requires a power wheelchair for mobility and 
performing daily activities. She would benefit from a group 3 power wheelchair with power tilt and recline 
since she does not have the upper extremity strength to adequately perform weight shifts and pressure relief. 
She would also benefit from a power seat elevator given that she requires assistance with transfers, and this 
would allow her to be more independent with transfers. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-approve a Group 3 power 
wheelchair with multiple power options (K0861) with accessories/seating  
 
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.