Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 standard power wheelchair with multiple power options 
(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), expandable controller (E2377), cushioned headrest (E0955), skin 
protection and positioning wheelchair seat cushion (E2607), positioning wheelchair back cushion (E2613), and 
adjustable angle footplate (K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options (K0861) 
and additional items and accessories (codes E1007, E1012, E2361, E1028, E2311, E2313, E2377, E0955, 
E2607, E2613, and K0040). You say that without the power wheelchair, the enrollee's mobility would be 
severely limited. You also say that you would like coverage to be approved for the power wheelchair with tilt 
and recline functions. The Plan denied your request. The Plan says that the enrollee does not have medical need 
for the multiple power options included with the requested K0861 group 3 power wheelchair with multiple 
power options. The Plan also says the electronic connection, expandable controller, and expandable controller 
harness cannot be covered as it is not medically necessary to control the three requested power options through 
the joystick (drive interface). 
 
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 multiple power options (K0861) and additional items and accessories (codes E1007, E1012, E2361, 
E1028, E2311, E2313, E2377, E0955, E2607, E2613, and K0040). Our reviewer says that the requested 
wheelchair and additional items and accessories are medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or walker for 
mobility. They cannot functionally propel a manual wheelchair due to upper extremity weakness and lack of 
coordination. Our reviewer found that 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 
his daily activities. Our physician reviewer found that they are noted to have 3 out of 5 motor strength in the 
upper extremities and cannot independently perform pressure relief. The enrollee is also noted to require 
assistance with transfers and requires assistance for re-positioning while in bed. The enrollee would therefore 
benefit from a group 3 power wheelchair with power tilt and recline given his neurological condition and 
inability to independently perform pressure relief. He would also benefit from power elevating leg rests for 
positioning of his lower extremities. These power options require an expandable controller with harness and 
electronic connection. Our reviewer found that therefore, the group 3 power wheelchair (K0861) with power 
tilt and recline (E1007) and power elevating leg rests (E1012) are medically necessary. The expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311) are also medically necessary to 
operate the power wheelchair and components as well as the joystick (E1028) and battery (E2361). Our 
physician reviewer found that the enrollee also requires seat (E2607) and back cushion (E2613) and a headrest 
(E0955) and footplate (K0040) to support themself. 
 
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 multiple power options (K0861) and 
additional items and accessories (codes E1007, E1012, E2361, E1028, E2311, E2313, E2377, E0955, E2607, 
E2613, and K0040) have been met. Therefore, we decided that the Plan has to pre-approve a group 3 standard 
power wheelchair with multiple power options (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), expandable 
controller (E2377), cushioned headrest (E0955), skin protection and positioning wheelchair seat cushion 
(E2607), positioning wheelchair back cushion (E2613), and adjustable angle footplate (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.