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 recline and 
accessories. We decided that the Plan does not have to pre-approve the power seat elevation system E2300 and 
upgraded electronics coded as E2377, E2313 and E2311.  
 
You asked the Plan to pre-approve Power wheelchair, group 3 standard, multiple power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0861) power seat elevation system 
(E2300)  group 24 sealed lead acid battery, each (E2363) expandable controller(E2377) harness for upgrade to 
expandable controller (E2313)  combination tilt and recline, with mechanical shear reduction  (E1007) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311)  
center mount power elevating leg rest/platform, complete system, any type, each (E1012)any type of cushioned 
headrest (E0955) manual swingaway, retractable or removable mounting hardware for joystick, other control 
interface, or positioning accessory (E1028) and positioning wheelchair seat cushion, 22 in depth (E0265). You 
say that please review the attached medical documentation to support the need of the custom medical 
equipment being requests. The Plan says that the enrollee does not meet the criteria for the requested special 
power wheelchair (group 3 power wheelchair) with 2 or more power options. 
 
We decided that the Plan has to pre-approve A Group 3 power wheelchair with power tilt and recline 
and accessories.  
 
We also decided that the Plan does not have to pre-approve the power seat elevation system E2300 and 
upgraded electronics coded as E2377, E2313 and E2311. 
 
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 enrollee partially meets the criteria for the requested power wheelchair. Our physician reviewer 
found based on the medical records provided there is documentation that a group 3 power wheelchair with 
power tilt and recline is needed for pressure reduction due to the presence of and history of pressure ulcers. The 
requested power seat elevation feature is statutorily non-covered as it serves no primary medical purpose. 
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 patient has significant edema of the lower extremities that requires a power elevating leg rest. Provided records document that the enrollee is independent with dressing 
and self-feeding thus indicating he has adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches. Thus, the expandable controller upgrade, harness and 
electronic connection do not meet criteria for coverage.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair have been met and the Medicare rules for coverage of the 
power seat elevation system and upgraded electronics have not been met. Therefore, we decided that the Plan 
has to pre-approve A Group 3 power wheelchair with power tilt and recline and the Plan does not have to pre-
approve the power seat elevation system E2300 and upgraded electronics coded as E2377, E2313 and 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.