Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options (K0861), a power seat elevation feature (E2300), an expandable controller (E2377), an expandable
controller harness (E2313), and an electro connect (E2311) to control power tilt, recline and power elevating
leg rests through the joystick.
You asked the Plan to pre-approve a group 3 power wheelchair, a power seat elevation feature, an expandable
controller, an expandable controller harness, and an electro connect. You say that the enrollee meets criteria for
the requested group 3 power wheelchair with multiple power options (K0861).
The requested power seat elevation feature (E2300), expandable controller (E2377), expandable controller
harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests
through the joystick are medically necessary. The Plan denied your request. The Plan says the enrollee does not
meet criteria for the requested group 3 power wheelchair with multiple power options (K0861). The requested
power seat elevation feature (E2300), expandable controller (E2377), expandable controller harness (E2313),
and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are
not medically necessary.
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, a power
seat elevation feature, an expandable controller, an expandable controller harness, and an electro connect. Our
reviewer says that the enrollee does not meet criteria for the requested group 3 power wheelchair with multiple
power options (K0861) and the requested power seat elevation feature (E2300), expandable controller (E2377),
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power
elevating leg rests through the joystick are not medically necessary. Our physician reviewer found the
documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily
living (MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due to inability to
walk and shoulder pain and limited range of motion (ROM). While the enrollee may be able to safely operate a
power wheelchair the requested K0861 with multiple power options exceeds the enrollee's medical need. The
documentation does not reveal that the enrollee needs are at a 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. The expandable controller (E2377), expandable controller harness (E2313), and
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article:
Wheelchair Options/Accessories - Policy Article (A52504). The enrollee does not require non-proportional
input devices (e.g., sip and puff, head array, etc.). The enrollee 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 enrollee does not need to control three power
options through a joystick. The E2300 power seat elevator is not medically necessary as it does not serve a
primary medical need. Also, the enrollee's upper extremity strength and function support that the enrollee can
control any power options through their own switches. The documentation does not reveal that tilt and recline
or power seat elevator are medically necessary therefore the request for Group 3 power wheelchair with
multiple power options is not medically necessary per Local Coverage Determination (LCD) guidelines
L33789 and LCD 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 a group 3 power wheelchair, a power seat elevation feature, an expandable
controller, an expandable controller harness, and an electro connect have not been met. Therefore, we decided
that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861), a
power seat elevation feature (E2300), an expandable controller (E2377), an expandable controller harness
(E2313), and an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the
joystick.