Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty with multiple power option 
(K0862), power seating system, combination tilt and recline (E1008), center mount power elevating leg 
rest/platform (E1012), manual swingaway, retractable or removable mounting hardware (E1028), group 34 
sealed lead acid battery (E2359), cushioned headrest (E0955), skin protection and positioning wheelchair seat 
cushion (E2608), positioning wheelchair back cushion (E2620), electronic connection between wheelchair 
controller and two or more power seating system motors (E2311) harness for upgrade to expandable controller 
(E2313) expandable controller (E2377), adjustable angle footplate (K0040), and wheelchair component or 
accessory (K0108).  
You asked the Plan to pre-approve a group 3 power wheelchair with two or more power seat options (power tilt 
and power recline options). You say that only a Group 3 (K0862) power wheelchair with both power tilt and 
power recline with power elevating leg rests will meet the enrollee's needs. You also say that this wheelchair 
does not exceed the enrollee's medical needs, and is medically necessary to meet their current medical needs. 
The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple power 
options included with the group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 a group 3 power wheelchair with two or 
more power seat options (power tilt and power recline options). Our reviewer says that a group 3 power 
wheelchair with two or more power seat options are not medically reasonable and necessary for the enrollee. 
Our physician reviewer found the record does not support that the enrollee requires a power wheelchair to 
manage mobility associated activities of daily living. 
 
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 with two or more power seat options (power tilt 
and power recline options) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 heavy duty with multiple power option (K0862), power seating system, combination tilt and 
recline (E1008), center mount power elevating leg rest/platform (E1012), manual swingaway, retractable or 
removable mounting hardware (E1028), group 34 sealed lead acid battery (E2359), cushioned headrest 
(E0955), skin protection and positioning wheelchair seat cushion (E2608), positioning wheelchair back cushion 
(E2620), electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) harness for upgrade to expandable controller (E2313) expandable controller (E2377), adjustable angle 
footplate (K0040), and wheelchair component or accessory (K0108).