Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power options (K0862) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2363, E2377, E2608, E2620, and K0108).  
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee requires the K0862 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 a qualifying diagnosis causing mobility limitation for a group 3 power 
wheelchair listed on the quote submitted. The Plan also says as the base code for the requested wheelchair is 
not reasonable and necessary, none of the requested accessories can be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0862) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 heavy duty power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the criteria for 
coverage have not been met. Our physician reviewer found the enrollee is functionally non-ambulatory and 
cannot use a cane or walker for mobility. They cannot functionally propel a manual wheelchair due to upper 
extremity weakness. Our reviewer found that the enrollee requires a power wheelchair for mobility and 
accomplishing their daily activities. However, the clinical documentation is insufficient why a lower-level 
power wheelchair would not meet the enrollees needs versus a group 3 power wheelchair. Our physician 
reviewer found that there is inadequate clinical documentation regarding the enrollees upper extremity and 
lower extremity motor strength and range of motion in the mobility evaluation. It is stated that they cannot 
perform pressure relief, but the enrollees wounds are in the lower extremities and due to an inappropriate fit 
for their manual wheelchair. This is not going to be addressed with power tilt and recline, which is for pressure 
relief on pressure bearing surfaces, and cannot adequately perform pressure relief. There is no history of skin 
breakdown. A group 3 power wheelchair base is typically indicated in patients with significant paralysis due to 
conditions such as a spinal cord injury. Our reviewer also found that it is understandable that the enrollee 
requires a power mobility device given their multiple medical conditions but there needs to be more 
information in the power mobility evaluation to necessitate a group 3 power wheelchair base. 
 
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 heavy duty 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 heavy duty power wheelchair with multiple power options (K0862) and additional items and 
accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2363, E2377, E2608, E2620, and K0108).