Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0862), an expandable 
controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power 
tilt, recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve a group 3 power wheelchair (K0862), an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. You say that the requested group 3 power wheelchair (K0862), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick are medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested group 3 power wheelchair (K0862), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not 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 to pre-approve a group 3 power wheelchair (K0862), 
an expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that the 
enrollee does not meet criteria for the requested group 3 power wheelchair (K0862), expandable controller 
harness (E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick. Our physician reviewer found the member has a neurologic disorder with functional 
deficits. Criteria for a power wheelchair are met but there is not a neurologic disorder to meet criteria for a 
group 3 power wheelchair. The documentation does not indicate that the member has any current pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or recline. The 
requested electrical accessories are not medically necessary as the member does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. The requested group 3 power wheelchair with accessories is not 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 (K0862), an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair (K0862), an expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick.