Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with accessories (K0848, E2361, 
E1028, E2620, and E2607). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with accessories. You say that the requested 
group 3 power wheelchair with accessories are medically necessary. The Plan denied your request. The Plan 
says that the enrollee does not meet criteria for a group 3 power wheelchair with accessories (K0848, E2361, 
E1028, E2620, and E2607). 
 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 with 
accessories. Our reviewer says that the enrollee meets criteria for a group 3 power wheelchair with accessories 
(K0848, E2361, E1028, E2620, and E2607). Our physician reviewer found based on the medical records 
provided there is documentation that this enrollee has a personal mobility deficit that impairs participation in 
mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary 
locations within the home. Based on the medical records provided there is documentation that the enrollee's 
mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to his level of 
weakness, poor coordination, dysmetria and instability. Based on the medical records provided there is 
documentation that the enrollee can safely operate a power mobility device. Based on the medical records 
provided there is documentation that the mobility limitation is due to a neurological condition (anoxic brain 
damage). Based on the medical records provided there is documentation that the specialty evaluation was 
performed by a licensed/certified medical professional. Based on the medical records provided there is 
documentation that the enrollee meets criteria for the requested group 3 power wheelchair and the requested 
accessories (including the positioning wheelchair back cushion and skin protection and positioning wheelchair 
seat cushion due to pelvic asymmetry) per Local Coverage Determination (LCD): Power Mobility Devices - 
L33789 and Local Coverage Determination (LCD) Wheelchair Seating (L33312). 
 
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 accessories have been met. Therefore, we 
decided that the Plan has to pre-approve a group 3 power wheelchair with accessories (K0848, E2361, E1028, 
E2620, and E2607).  
 
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.