Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve procedure codes K0861, E0953, E0955, E0956, E0957, E0957, 
E0960, E1007, E1012, E1028, E2377, E2620, and E2624. We decided that the Plan does not have to pre-
approve procedure codes K0108 and E2300.  
 
You asked the Plan to pre-approve procedure codes K0861, E0953, E0955, E0956, E0957, E0957, E0960, 
E1007, E1012, E1028, E2377, E2620, E2624, K0108 and E2300. You say that the requested items are medically necessary for the enrollee. The Plan says that the requested Group 3 power wheelchair is not 
medically necessary. 
 
We decided that the Plan has to pre-approve procedure codes K0861, E0953, E0955, E0956, E0957, 
E0957, E0960, E1007, E1012, E1028, E2377, E2620, and E2624.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered if certain criteria are 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 procedure codes K0861, E0953, E0955, 
E0956, E0957, E0957, E0960, E1007, E1012, E1028, E2377, E2620, and E2624. Our reviewer says that the 
requested Group 3 power wheelchair with tilt and reline and accessories are medically reasonable and 
necessary. Our physician reviewer found the provided documentation indicates that the enrollee requires a 
power wheelchair for mobility and accomplishing her daily activities. The reviewer found that the 
documentation indicates the enrollee has a neurological disease that necessitates a group 3 power wheelchair. 
The reviewer found that the documentation indicates the enrollee's upper extremities fatigue. The enrollee will 
progressively have upper extremities weakness which impedes their ability to perform independent pressure 
relief. The documentation indicates the need for power elevating leg rests given the enrollee's positioning needs 
and lower extremity spasticity. The documentation also indicates the enrollee requires supports for positioning 
and appropriate pressure relief. Therefore, the reviewer found that a power wheelchair with power tilt and 
recline is medically reasonable and 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 procedure codes K0861, E0953, E0955, E0956, E0957, E0957, E0960, E1007, 
E1012, E1028, E2377, E2620, and E2624 have been met. Therefore, we decided that the Plan has to pre-
approve procedure codes K0861, E0953, E0955, E0956, E0957, E0957, E0960, E1007, E1012, E1028, E2377, 
E2620, and E2624.  
 
We also decided that the Plan does not have to pre-approve procedure codes K0108 and E2300. 
 
The gel pads and power seat elevation system at issue in this appeal do not serve a purpose that is primarily 
medical in nature. These items are available to the general public and would be helpful even to those who are 
not sick or injured. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K0108 and E2300 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve procedure codes K0108 and E2300. 
 
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.