Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with power tilt and remaining 
accessories. We decided that the Plan does not have to pre-approve upgraded electronics coded as E2311.  
 You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair is an upgrade to the current group 2 power wheelchair based on medical necessity. 
The Plan says that enrollee does not meet criteria as the enrollee has a group 2 power wheelchair that meets 
their needs. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair with power tilt and remaining 
accessories.  
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. 
Congenital skeletal deformity. 
 
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 for a group 3 power wheelchair with power tilt and 
remaining accessories. Our physician reviewer found clinical documentation shows that the enrollee meets 
criteria for group 3 power wheelchair and that the enrollee is not able to effectively pressure relief thus a group 
3 power wheelchair with accessories and power tilt is 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 a group 3 power wheelchair with power tilt and remaining accessories have 
been met. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with power tilt 
and remaining accessories.  
 
We also decided that the Plan does not have to pre-approve upgraded electronics coded as E2311. 
 
The Plan must follow Medicare rules. The rules say if a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-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 for upgraded electronics codes as E2311. Our reviewer 
says that upgraded electronics coded as E2311 are not necessary. Our physician reviewer found there is no 
documentation to support upgraded electronics coded as E2311. There is only one power option and no 
documentation to show that the enrollee would not be able to use that feature or its own switch.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics coded as E2311 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve upgraded electronics coded as E2311. 
 
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.