Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856), a Power 
wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (E2363), a 
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other 
control interface or positioning accessory (E1028 x 2), a Wheelchair accessory, power seating system, tilt only 
(E1002), a Positioning wheelchair seat cushion, width less than 22 inches, any depth (E2605), a Wheelchair 
accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, 
any type, each (E1012), a Wheelchair accessory, headrest, cushioned, any type, including fixed mounting 
hardware, each (E0955). 
 You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair with single power option (K0856) and accessories (E0955, E1002, E1012, E1028, 
E2363, and E2605 are medically necessary.  The Plan denied your request. The Plan says the enrollee does not 
meet criteria for a group 3 power wheelchair with single power option (K0856) and accessories (E0955, E1002, 
E1012, E1028, E2363, and E2605.  
 
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 and 
accessories. Our reviewer says that the enrollee does not meet criteria for a group 3 power wheelchair with 
single power option (K0856) and accessories (E0955, E1002, E1012, E1028, E2363, and E2605.  Our 
physician reviewer found the enrollee has used a wheelchair chronically because of multiple sclerosis (MS). He 
is in assisted living and uses a lift for transfer. He can walk short distances. He has intact skin and a suprapubic 
catheter. The enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing power drive. 
 
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 and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Power wheelchair, group 3 standard, single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856), a Power wheelchair 
accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (E2363), a Wheelchair 
accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface 
or positioning accessory (E1028 x 2), a Wheelchair accessory, power seating system, tilt only (E1002), a 
Positioning wheelchair seat cushion, width less than 22 inches, any depth (E2605), a Wheelchair accessory, 
addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, 
each (E1012), a Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each 
(E0955).