Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E2300, E2363, E1002, E2605, E1012, 
E0955, E1028, E0953, E1028, and E1028). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you would like the provided medical documentation to be reviewed to support the need of the 
custom medical equipment being requested for the enrollee. The Plan denied your request. The Plan says the 
enrollee does not have need for single power option for which a K0856 group 3 power wheelchair is medically 
needed. The Plan also says that a headrest not medically needed.  
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the base power wheelchair is not covered, all related accessories will also 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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 3 power wheelchair with power tilt, 
power seat elevator, and power elevating leg rests is not medically necessary. Our physician reviewer found the 
enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility. They have greater 
proximal than distal motor strength deficits and cannot functionally propel a manual wheelchair due to upper 
extremity weakness. The enrollee cannot operate a power scooter due to an impaired ability to transfer. 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 
suffice for their needs versus a group 3 power wheelchair. There is inadequate clinical documentation 
regarding why the enrollee requires power tilt and power elevating leg rests with a group 3 power wheelchair 
base. They have no history of skin breakdown and has intact sensation. The enrollee has fair sitting balance and 
there is no significant lower extremity edema. Our physician reviewer also found that the enrollee does not 
have complex seating needs and group 3 power wheelchairs are typically indicated for patients with total 
paralysis, such as with spinal cord injury. 
 
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 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 single power option (K0856) and additional items and accessories (codes E0955, E2300, 
E2363, E1002, E2605, E1012, E0955, E1028, E0953, E1028, and E1028).