Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair (PWC) with multiple 
power options and accessories coded as K0861, E2361, E2377, E2313, E1028, E1007, E2311, E1012, K0040, 
E2609, E2617, E0955. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee lives in a nursing home, and 
you requested a place of service denial. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for the requested Group 3 power wheelchair with multiple power options. 
 
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 the power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Based on the medical records provided there is documentation that the enrollee's 
mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to his level of 
instability and weakness and there is documentation that the enrollee can safely operate a power mobility 
device. The provided records do not document the patient has a musculoskeletal condition or the presence of a 
cast or brace which prevents 90-degree flexion at the knee, or the enrollee has significant edema of the lower 
extremities that requires an elevating legrest. Provided records do not support that the enrollee is high risk for 
skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. The records do not document 
the enrollee performs bladder self-catheterization and is unable to transfer independently or that the enrollee 
has increased muscle tone or spasticity to support necessity of the power tilt/recline. As the power elevating 
legrest and the power tilt/recline do not meet criteria for coverage, the multiple power option wheelchair base 
does not meet coverage criteria, 
 
We looked at this physician's review, the file, and Medicare rules. The appellant also indicated that the enrollee 
resides in a nursing home and the denial requested was for place of service.  The rules say that for equipment to 
be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a 
hospital to be a home.  The records also shows that the power wheelchair is being requested for use in a SNF or 
hospital. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair 
(PWC) with multiple power options and accessories coded as K0861, E2361, E2377, E2313, E1028, E1007, 
E2311, E1012, K0040, E2609, E2617, E0955.