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, E1002, E1012, E1028, E2300, E2361, and 
E2603). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the attached complex power wheelchair is the most appropriate and lowest cost alternative for the 
enrollee to safely meet all their daily needs independently. The Plan denied your request. The Plan says the 
enrollee does not have medical need for single power option included with a K0856 group 3 power wheelchair. 
The Plan also says that power elevating leg rests are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (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 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 standard power wheelchair 
and additional items and accessories. Our reviewer says that based on the medical records provided there is no 
documentation that the Group 3 standard power wheelchair with single power option (K0856) and additional 
items and accessories (codes E0955, E1002, E1012, E1028, E2300, E2361, and E2603) at issue in this case 
meets all Medicare criteria for medically reasonable and necessary for the enrollee. Our physician reviewer 
found the provided records from the enrollee's treating physician do not support that the enrollee is high risk for 
skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery; the physician notes report left 
sided weakness, but no right-sided weakness and records report intact sensation. The records do not document 
the enrollee performs bladder self-catheterization or that they have increased muscle tone or spasticity to meet 
criteria for the power tilt and thus the single power option base. Our reviewer found that as the requested 
wheelchair base does not meet Medicare coverage criteria, the requested accessories are not covered.  
 
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, E1002, 
E1012, E1028, E2300, E2361, and E2603).  
 
Please Note: The Plan did not issue a denial specific to the requested code K0848, therefore, we do not have 
jurisdiction to render a decision on this code. You can submit another appeal to the Plan for this code if you 
wish.