Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 standard power wheelchair, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E2363 x2, E2323, E1028, E2377, E2313, E2311, E0956 x2, E1028 x2, E2624, K0108, 
E1028, K0108, E1028, E0955, E1028, E0953 x2, E1028 x2, K0108, E0960, E2300, E1007, and E1012). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says that you do 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 expandable controller harness cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
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 the durable medical equipment (DME). 
Our physician reviewer found documentation dated July 26, 2023, indicated that you are functionally non-
ambulatory and are requiring assistance with stand pivot transfers. You currently are using a group 3 power 
wheelchair for mobility that is on loan.  You are requiring assistance with daily activities, including toileting, 
dressing, and bathing/showering. Motor strength in the upper extremities is noted to be 2/5 and 2/5 in the lower 
extremities. Sensation is intact. There is no history of skin breakdown. You are noted to have spasticity in the 
lower extremities. You are functionally non-ambulatory and cannot use a cane or walker for mobility. You 
cannot functionally propel a manual wheelchair due to upper extremity weakness. You require a power 
wheelchair for mobility and accomplishing their daily activities. You cannot perform pressure relief 
independently due to upper extremity weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. Power elevating leg rests are required for positioning of the lower 
extremities and lower extremity spasticity. A power seat elevator is needed for assistance with transfers since 
you can perform stand pivot transfers with assistance. The complexity of your seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. The expandable controller with harness and 
electronic connection are necessary to operate the group 3 power wheelchair base and the three power options 
via a joystick. These components are required to operate 3 or more power options on a group 3 power 
wheelchair. Therefore, the group 3 power wheelchair with power tilt & recline, power elevating leg rests and 
power seat elevator is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve a group 3 standard power wheelchair, multiple power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E2363 x2, E2323, E1028, E2377, E2313, E2311, E0956 x2, E1028 x2, E2624, K0108, 
E1028, K0108, E1028, E0955, E1028, E0953 x2, E1028 x2, K0108, E0960, E2300, E1007, and E1012).  
 
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.