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 (K0861), an expandable controller (E2377), an expandable controller harness (E2313), and an electro 
connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (K0861), an 
expandable controller (E2377), an expandable controller harness (E2313), and an electro connect (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick. You say that the requested items 
are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 with 
multiple power options (K0861), an expandable controller (E2377), an expandable controller harness (E2313), 
and an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. 
Our reviewer says that the enrollee does not meet criteria for the requested items. Our physician reviewer found 
based on the medical records provided there is no documentation that the enrollee meets Local Coverage 
Article: Wheelchair Options/Accessories - Policy Article (A52504) criteria for the requested group 3 power 
wheelchair with multiple power options (power tilt and power recline) (K0861). Provided records do not 
document that the enrollee is at high risk for skin breakdown; she transfers independently; she has no current 
pressure ulcer and no history of pressure ulcer or flap surgery. There is no documentation that she requires 
urinary self-catheterization. There is no clear documentation of spasticity or increased muscle tone on 
examination of the enrollee to require the multiple power options with power tilt and power recline. 
 
Provided records do not document a covered indication for the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick per LCA A52504. Provided records document that the enrollee has 4/5 
right upper extremity strength and is independent with eating thus indicating she has adequate upper extremity 
strength and function to operate the wheelchairs power options with their own switches. 
 
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 with multiple power options (K0861), an 
expandable controller (E2377), an expandable controller harness (E2313), and an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick 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 
(K0861), an expandable controller (E2377), an expandable controller harness (E2313), and an electro connect 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick.