Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (K0861) and accessories (E2363, 
E2311, E2313, E2377, E2609, E0953, E2617, E0955, E1007, E1012, E1028). We decided that the Plan does 
not have to pre-approve the power seat elevation feature (E2300) and gel pads (K0108).  
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that a power wheelchair and 
accessories are medically necessary. The Plan denied your request. The Plan says that the requested items are 
not medically necessary. 
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (K0861) and accessories 
(E2363, E2311, E2313, E2377, E2609, E0953, E2617, E0955, E1007, E1012, E1028).  
 
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 power wheelchair and related 
accessories. Our reviewer says that the coverage criteria has been met. Our physician reviewer found that the 
Group 3 wheelchair with power tilt and recline meet the coverage criteria due to the enrollees inability to 
ambulate due to muscular dystrophy with a reported history of skin breakdown, inability to transfer, and high 
risk of skin breakdown. The provided records document that the enrollee has 1+/5 to 2-/5 upper extremity 
strength and requires >75% assistance with daily activities thus indicating he has inadequate upper extremity 
strength and function to operate the wheelchairs power options with their own switches, thus upgraded 
electronics (E2311, E2313, E2377) are medically necessary. The provided records also document the enrollee 
has significant edema of the lower extremities that requires a power elevating leg rest (E1012). The battery 
(E2363), seat cushion (E2609, lateral thigh or knee support (E0953), back cushion (E2617), headrest (E0955), 
and manual swingaway joystick (E1028) are required for proper operation of and positioning in the wheelchair.  
 
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 the related accessories have been met. Therefore, we 
decided that the Plan has to pre-approve a Group 3 power wheelchair (K0861) and accessories (E2363, E2311, 
E2313, E2377, E2609, E0953, E2617, E0955, E1007, E1012, E1028). 
 
We also decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and 
gel pads (K0108). 
 
The Plan follows Medicare rules. Medicare rules say that items that are not primarily medical in nature are not 
covered.  
 
We looked at the file and Medicare rules. The requested power seat elevation feature and gel pads are not 
primarily medical in nature and service no medical purpose. Therefore, we decided that the Plan does not have 
to pre-approve the power seat elevation feature (E2300) and gel pads (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.