Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with combination tilt and recline, 
power elevating leg rest and components coded as K0861, E0953, E0955, E1007, E1012, E1028, E2363, 
E2605. We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) 
electronic connection between 2 systems (E2311) and a power seat elevation system (E2300).  
 
You asked the Plan to pre-approve the Group 3 power wheelchair with seat elevator and upgraded electronics 
coded as K0861, E0953, E0955, E1007, E1012, E1028, E2363, E2605, E2377, E2313, E2311 and E2300.. You 
say that you ask for review of the attached documentation for reconsideration and approval of the 
recommended DME. The Plan says that the enrollee does not have medical need for multiple power options 
available with K0861 group 3 power wheelchair. The seat elevator and upgraded electronics are not medically 
needed.  
 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with combination tilt and 
recline, power elevating leg rest and components coded as K0861, E0953, E0955, E1007, E1012, E1028, 
E2363, E2605.  
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 Group 3 power wheelchair with 
upgraded electronics. Our reviewer says that the enrollee partially meets the criteria for the requested power 
wheelchair and components. 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 and cannot operate a power scooter due to impaired sitting balance and upper 
extremity strength. The enrollee requires a power wheelchair for mobility and accomplishing daily activities. 
The enrollee has a progressive neurological disease and does not have the level of functional upper extremity 
strength to adequately perform pressure relief. Therefore, the enrollee requires a Group 3 power wheelchair 
with power tilt and recline for adequate pressure relief and power elevating leg rests for positioning and lower 
extremity edema. A group 2 power wheelchair would not meet the complexity of her seating needs with power 
tilt and recline and impaired sitting balance. Therefore, the group 3 power wheelchair with power tilt and 
recline and power elevating leg rests 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 Group 3 power wheelchair have been met. Therefore, we decided that the 
Plan has to pre-approve a Group 3 power wheelchair with combination tilt and recline, power elevating leg rest 
and components coded as K0861, E0953, E0955, E1007, E1012, E1028, E2363, E2605.   
We also decided that the Plan does not have to pre-approve expandable controller (E2377) harness 
(E2313) electronic connection between 2 systems (E2311) and a power seat elevation system (E2300). 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
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 expandable controller (E2377) harness 
(E2313) electronic connection between 2 systems (E2311) and a power seat elevation system (E2300). Our 
reviewer says that the provided records document that the enrollee has 3/5 bilateral upper extremity strength 
and has enough arm strength and dexterity to manipulate the controls, thus indicating the enrollee has adequate 
upper extremity strength and function to operate the wheelchairs power options with their own switches.  
The provided records from the treating physician do not document that the enrollee requires the seat elevation 
feature for performing transfers or for reaching from the power wheelchair to complete one or more mobility 
related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in 
customary locations within the home as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller (E2377) harness (E2313) electronic connection between 2 
systems (E2311) and a power seat elevation system (E2300) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve expandable controller (E2377) harness (E2313) electronic connection 
between 2 systems (E2311) and a power seat elevation system (E2300). 
 
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.