Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with two (2) or more power 
seat options and accessories (K0861, E2361, E1028x2, E1007, K0108, E0955, E1012, E2311, E2311, E2313, 
E2601). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says you do not meet criteria 
for the requested wheelchair and power options. Documentation does not show that you are at high risk for skin 
breakdown, you have no current skin ulcers or history of pressure ulcers, and you have no history of flap 
surgery. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically reasonable or necessary. Our physician reviewer found the 
documentation indicates you have a mobility deficit that impairs MRADLs in the home and you are 
ameliorated by a walker, cane, manual wheelchair due to pain, unsteadiness, weakness. While you may be able 
to safely operate a PMD, the requested wheelchair with multiple power options exceeds your medical need. 
You do have a group 3 qualifying neurologic diagnosis, but the documentation does not reveal that your needs 
are 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. You do not require non-
proportional input devices (e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., for 
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer 
through the chair's drive control), 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). Your strength 
and functional ability should be sufficient to control any power options through their own switches. The 
documentation does not reveal that tilt and recline are medically necessary or the expandable controller, the 
harness and electronic connection between are medically necessary. Therefore, the request for group 3 power 
wheelchair with multiple power options is not 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair with two (2) or more power seat options 
and accessories (K0861, E2361, E1028x2, E1007, K0108, E0955, E1012, E2311, E2311, E2313, E2601).