Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861), lateral thigh or knee support (E0953), cushioned headrest (E0955), positioning 
wheelchair seat cushion (E2605), positioning wheelchair back cushion (E2620), combination tilt and recline 
(E1007), center mount power elevating leg rest/platform (E1012), arm trough (E2209), group 24 sealed lead 
acid battery (E2363), retractable or removable mounting hardware for joystick (E1028), power seat elevation 
system (E2300), electronic connection (E2311), harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee requires the K0861 base and all recommended 
components to meet their mobility, medical, and functional needs in their home. The Plan denied your request. 
The Plan says the enrollee does not have medical need for multiple power options included with K0861 group 
3 power wheelchair. The Plan also says the electronic connection, expandable controller, and harness cannot be 
covered, as it is not medically necessary to control the three requested power options through the joystick 
(drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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 group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the criteria for 
coverage are not met. Our physician reviewer found the enrollee has a Braden score of 16 indicating mild risk 
for skin breakdown. The enrollee does not use a catheter or require positioning because of spasms. Our 
reviewer also found that the enrollee does not require tilt and recline and does not require alternative means of 
controlling power drives as he has adequate upper body strength to manage standard power drives. 
 
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 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861), lateral thigh or knee 
support (E0953), cushioned headrest (E0955), positioning wheelchair seat cushion (E2605), positioning 
wheelchair back cushion (E2620), combination tilt and recline (E1007), center mount power elevating leg 
rest/platform (E1012), arm trough (E2209), group 24 sealed lead acid battery (E2363), retractable or removable 
mounting hardware for joystick (E1028), power seat elevation system (E2300), electronic connection (E2311), 
harness (E2313), and expandable controller (E2377).