Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair with multiple power option 
(K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2359, 
E2377, E2622, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that Medicare has approved this request, and you would like this to be reviewed and overturned. The 
Plan denied your request. The Plan says that the enrollee does not have medical need for multiple power 
options included with a K0861 group 3 power wheelchair. The Plan also says the electronic connection, 
harness, and expandable controller cannot be covered as it is not medically necessary to control the three 
requested power options through the joystick (drive interface). 
 
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 a Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee is functionally non-
ambulatory, cannot use a cane or walker for mobility, and is at high risk for falling. They cannot functionally 
propel a manual wheelchair due to upper extremity weakness and compromised cardiac and respiratory 
function. Our reviewer found that the enrollee requires a power wheelchair for mobility and accomplishing 
their daily activities. Power tilt and recline is required given that the enrollee cannot adequately perform 
pressure relief. The enrollee is noted to require moderate assistance with bed mobility and has upper extremity 
weakness. The enrollee requires power elevating leg rests for positioning and lower extremity edema. Our 
physician reviewer also found that given their diagnosis of inclusion body myositis, the enrollee requires a 
more complex Group 3 power wheelchair base given their positioning and suspension needs. 
 
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 
been met. Therefore, we decided that the Plan has to pre-approve a Group 3 standard power wheelchair with 
multiple power option (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, 
E2311, E2313, E2359, E2377, E2622, and K0040).  
 
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.