Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options, a 
combination tilt and recline power seating system, electronic connection, and battery. We decided that the 
Plan does not have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options (K0561), a 
combination tilt and recline power seating system (E1007), electronic connection (E2311), battery (E2311) and 
a power seat elevation system (E2300). You say that this is medically necessary. The Plan says that that the 
member does not have a medical need for the F3 Base Corpus PWC with tilt AND recline power options. 
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options, a 
combination tilt and recline power seating system, electronic connection and battery.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered if 
Medicare rules have been 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 a Group 3 power wheelchair with 
multiple power options, a combination tilt and recline power seating system, electronic connection and battery. 
Our reviewer says that a Group 3 power wheelchair with multiple power options, a combination tilt and recline 
power seating system, electronic connection and battery are medically reasonable and necessary. The patient 
has a documented clinical indication for a group 3 power wheelchair, has multiple pain issues with spasticity thus qualifying for recline and elevating leg rests; has stage 2 pressure ulcer and documented inability to fully 
pressure offload thus meeting criteria for power tilt. Patient documented as wheelchair bound with ADL 
impairments with functional independence not met by other DME, is able to use a PMD in home and has 
means to use a PMD. Our physician reviewer found that the enrollee's condition meets criteria for coverage of a 
Group 3 power wheelchair with multiple power options, a combination tilt and recline power seating system, 
electronic connection and battery.  
 
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 multiple power options, a combination tilt 
and recline power seating system, electronic connection and battery have been met. Therefore, we decided that 
the Plan has to pre-approve a Group 3 power wheelchair with multiple power options, a combination tilt and 
recline power seating system, electronic connection and battery.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because 
it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of 
a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation system. 
 
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.