Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the requested group 3 wheelchair (K0862) and all of the 
requested accessories except for code E2300. We decided that the Plan does not have to pre-approve code 
E2300.  
 
You asked the Plan to pre-approve a group 3 power wheelchair (code K0862) with the following accessories: 
E2311 (electronic connection between wheelchair controller and 2 or more power seating system motors), 
E1028 (retractable or removable hardware), E2313 (harness), E2300 (power seat elevation system), E2625 
(seat cushion), E0953 (thigh/knee support), E2363 (battery), E1012 (power elevating leg rest), E2377 
(expandable controller), E1007 (power tilt and recline system), and E0955 (headrest). You say that member has 
a hereditary neurodegenerative disease, spinocerebellar ataxia type 3 (SCA3) that causes progressive cerebellar 
ataxia, high fall risk, limb incoordination and slurred speech. His condition has progressed to the point that he 
cannot walk even short distances with a walker any longer. In addition, he weighs 320 lbs. and his wife is 
unable to significantly mitigate the risk of falling. He is not able to operate a manual wheelchair well but is 
capable of controlling a motorized wheelchair.  
 
The Plan says that although the member meets criteria for a group 3 power wheelchair, he does not meet 
criteria for the specific chair requested because he does not need multiple power options.  The patient is not at 
high risk for development of pressure ulcers, so the requested power tilt/recline is not covered.  In addition, one 
of the other requested power options (E2300) is not a covered benefit.  Therefore, the patient does not require 
the specific chair requested because he does not need multiple power options. 
 
We decided that the Plan has to pre-approve the requested group 3 wheelchair (K0862) and all of the 
requested accessories except for code E2300. 
 
The Plan follows Medicare rules. Medicare rules say that group 3 power wheelchairs with multiple power 
options are coverable for patients who require multiple power options.  For power tilt/recline features, these are 
coverable for patients who are at high risk for development of a pressure ulcer and are unable to perform a 
functional weight shift.  Other wheelchair options and accessories are covered when medically necessary. 
 
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 requested wheelchair and 
accessories. Our reviewer says that the requested group 3 power wheelchair with multiple power options and 
all but 1 of the accessories are considered medically necessary in this case. Our physician reviewer found the 
clinical documentation shows that patient has a neurodegenerative diagnosis and would require a group 3 
power mobility device with accessories due to functional and neurological impairments. The wheelchair 
evaluation shows that patient has impaired upper limb function both in strength and range of motion with 
inability to effectively pressure relieve, thus power tilt and recline with upgraded electronics (electronic 
connection from power options to joystick) is also 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 the requested group 3 wheelchair (K0862) and all of the requested accessories 
except for code E2300. have been met. Therefore, we decided that the Plan has to pre-approve the requested 
group 3 wheelchair (K0862) and all of the requested accessories except for code E2300. 
 
We also decided that the Plan does not have to pre-approve the power seat elevation feature (code 
E2300). 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation systems (E2300) are non-
covered because they are not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of code E2300 have not been met. Therefore, we decided that the Plan does not have to pre-
approve the power seat elevation system (code 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.