Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options represented by code K0861 and for related accessories represented by codes K0108, E2363, E1028, 
E2377, E2313, E1007, E2300, E2620, E0955, E1028, E0960, E2607, and E2311. 
 
You asked the Plan to pre-approve codes K0861, K0108, E2363, E1028, E2377, E2313, E1007, E2300, E2620, 
E0955, E1028, E0960, E2607, and E2311. You say that the documentation provided supports the need for the 
requested items. You say that the requested wheelchair and accessories will ensure that the enrollee will not 
develop more wounds or become hospitalized. The Plan denied your request. The Plan says the enrollee does 
not have a medical need for multiple power options included in the K0861 group 3 power wheelchair. The Plan 
says that the enrollee meets the criteria for a Group 3 power wheelchair with no power options but does not 
meet the criteria for tilt and recline features and therefore does not meet the criteria for base code power 
wheelchair group 3 with multiple power options. The Plan says that the documentation does not show that the 
enrollee is at high risk for development of skin ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also says that a power seat elevation feature (E2300) is not covered 
as it is not primarily medical in nature. 
 
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 codes K0861, K0108, E2363, E1028, 
E2377, E2313, E1007, E2300, E2620, E0955, E1028, E0960, E2607, and E2311. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested K0861 with multiple power options exceeds the enrollee's medical need. The enrollee does 
have a Group 3 qualifying neurologic diagnosis of a stroke, but the documentation does not reveal that the 
enrollee needs is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for 
bladder management, or needs a power seating system to manage increased tone or spasticity. The enrollee 
does not require non-proportional input devices. The enrollee does not require a separate display, other 
electronic devices, or an attendant control. The documentation does not support that it is medically necessary to 
control the requested power options through the joystick (drive interface). The enrollee's functional ability is 
sufficient to control any power options through their own switches. The documentation does not reveal that the 
items in dispute are 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 codes K0861, K0108, E2363, E1028, E2377, E2313, E1007, E2300, E2620, 
E0955, E1028, E0960, E2607, and E2311 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options represented by code K0861 and 
for related accessories represented by codes K0108, E2363, E1028, E2377, E2313, E1007, E2300, E2620, 
E0955, E1028, E0960, E2607, and E2311.