Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve procedure codes K0861, E2361 x 2, E1007, E2620, E0955, 
E1028, E1012, E2377, E2313, E2311, E2607, and E1028. We decided that the Plan does not have to pre-
approve procedure codes E2300 and K0108.  
 
You asked the Plan to pre-approve procedure codes K0861, E2361 x 2, E1007, E2620, E0955, E1028, E1012, 
E2377, E2313, E2311, E2607, E1028, E2300, and K0108. You say that the enrollee is no longer able to 
ambulate safely or functionally. You say that the enrollee has had a significant decline in function. You also 
say that power tilt and recline are necessary for proper support, positioning, and pressure relief. The Plan says 
that a group 3 power wheelchair with multiple power options is medically necessary both power tilt and power 
recline are required. The Plan says that upgraded electronics are not medically necessary. The Plan also says 
that a backpack holder and seat lift do not serve a medical need. 
 
We decided that the Plan has to pre-approve procedure codes K0861, E2361 x 2, E1007, E2620, E0955, 
E1028, E1012, E2377, E2313, E2311, E2607, and E1028.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered if certain criteria are met.  
 
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 
power tilt and recline and accessories. Our reviewer says that the requested group 3 power wheelchair and 
accessories are medically necessary. Our physician reviewer found the enrollee has a neurological condition. 
The reviewer found that the enrollee is non-ambulatory and cannot use a cane or walker for mobility. The 
enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness and impaired 
cardiorespiratory function. The enrollee cannot operate a power scooter due to impaired sitting balance and 
impaired ability to transfer. The enrollee requires a power wheelchair for mobility and accomplishing daily activities. The enrollee cannot perform pressure relief and is at risk for skin breakdown and therefore requires 
power tilt and recline. The enrollee also requires power leg rests to positioning and due to lower extremity 
contracture. The expandable controller and electronic connection and harness are necessary to operate the 
power wheelchair and power components. The back, headrest and seat cushion are needed for pressure relief as 
well as the mounting hardware. Therefore, the requested 3 power wheelchair with power tilt and recline and 
power leg elevator and upgraded electronics are 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 the Group 3 power wheelchair with power tilt and recline and accessories have 
been met. Therefore, we decided that the Plan has to pre-approve procedure codes K0861, E2361 x 2, E1007, 
E2620, E0955, E1028, E1012, E2377, E2313, E2311, E2607, and E1028.  
 
We also decided that the Plan does not have to pre-approve procedure codes E2300 and K0108. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
The power elevation system (E2300) and backpack holder (K0108) do not serve a purpose that is primarily 
medical in nature. These items are available to the general public and would be helpful even to those who are 
not sick or injured. Therefore, we decided that the Plan does not have to pre-approve procedure codes E2300 
and K0108. 
 
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.