Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (K0862), an expandable controller 
(E2377), and an expandable controller harness (E2313). We also decided that the Plan does not have to pre-
approve a privacy bag (K0108). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair (K0862), an expandable controller (E2377), an 
expandable controller harness (E2313), and a privacy bag (K0108). You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchairs  
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (K0862), an expandable 
controller (E2377), and an expandable controller harness (E2313). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 a Group 3 power wheelchair (K0862), 
an expandable controller (E2377), and an expandable controller harness (E2313). Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that the enrollee is non-ambulatory and cannot 
use a cane or walker for mobility. The enrollee cannot functionally propel a manual wheelchair due to upper 
extremity weakness and impaired cardiorespiratory function and cannot operate a power scooter due to 
impaired sitting balance and the limited turning radius. A power wheelchair is necessary for mobility and 
accomplishing his daily activities. The enrollee also requires a Group 3 power wheelchair with power tilt and 
recline and power elevating leg rests due to a neurological condition. The enrollee cannot independently 
perform pressure relief due to upper extremity weakness and requires power tilt and recline for adequate 
pressure relief given that he is at risk for skin breakdown. The enrollee has impaired hand strength and 
coordination due to his neurological condition and requires the power options and power wheelchair to be 
operated via a joystick. Therefore, the expandable controller, harness, and electronics are required. 
 
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), and an 
expandable controller harness (E2313) have been met. Therefore, we decided that the Plan has to pre-approve a 
Group 3 power wheelchair (K0862), an expandable controller (E2377), and an expandable controller harness 
(E2313).  
 
We also decided that the Plan does not have to pre-approve a privacy bag (K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a privacy bag (K0108).   
 
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.