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, patient weight capacity up to and including 300 pounds (K0861), combination tilt and recline 
(E1007), center mount power elevating leg rest/platform (E1012), 22nf sealed lead acid battery (E2361), 
retractable or removable mounting hardware for joystick (E1028), electronic connection (E2311), harness 
(E2313), specialty joystick handle for hand control interface (E2323), expandable controller (E2377), 
cushioned headrest (E0955), skin protection and positioning wheelchair seat cushion (E2607), and positioning 
wheelchair back cushion (E2620). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with additional items and accessories. 
You say that you find it hard to believe that a physician reviewer had looked at all the supplied documentation 
and came to the conclusion to deny this power wheelchair for the enrollee. The Plan denied your request. The 
Plan says the enrollee does not have medical need for multiple power options included with a K0861 group 3 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 additional items and accessories. Our reviewer says that the group 3 power wheelchair with power tilt and 
recline is not medically necessary. Our physician reviewer found the enrollee is functionally non-ambulatory 
and cannot use a cane or walker for mobility. The enrollee cannot functionally propel a manual wheelchair due 
to upper extremity weakness. The enrollee cannot operate a power scooter due to impaired sitting balance and 
upper extremity strength. The enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. Our reviewer found that however, the clinical documentation is insufficient why a lower-level power 
wheelchair would not suffice for the enrollee's needs versus a group 3 power wheelchair. There is inadequate 
clinical documentation regarding why the enrollee requires power tilt and recline and cannot perform pressure 
relief. The enrollee has no history of skin breakdown and is noted to require minimal assistance for transfers. 
The enrollee is noted to have 2 to 3 out of 5 motor strength in the upper extremities, but at the same time can 
ambulate with a walker, although non-functionally. Our physician reviewer also found that the enrollee's level 
of function does not correlate with their motor strength and no other information is provided in terms of what 
level of assistance they require with daily activities. 
 
 
 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 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, patient weight capacity up to and including 300 pounds (K0861), 
combination tilt and recline (E1007), center mount power elevating leg rest/platform (E1012), 22nf sealed lead 
acid battery (E2361), retractable or removable mounting hardware for joystick (E1028), electronic connection 
(E2311), harness (E2313), specialty joystick handle for hand control interface (E2323), expandable controller 
(E2377), cushioned headrest (E0955), skin protection and positioning wheelchair seat cushion (E2607), and 
positioning wheelchair back cushion (E2620).