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) and additional items and accessories (codes E2300, E2311, E2313, E2377, E0953, E0955, E0960, 
E1007, E1012, E1028, E2361, E2620, and E2622). 
 
  You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that the enrollee is non-ambulatory, cannot walk or stand, and has a 
catheter. You also say that the specific chair with adjustment options will allow the enrollee to alleviate their 
pain. The Plan denied your request. The Plan says that the enrollee does not have medical need for multiple 
power options included with 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 follows Medicare rules. Medicare rules say that a group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also 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 
with multiple power options and additional items and accessories. Our reviewer says that this request is 
medically necessary. Our physician reviewer found that the patient is non-ambulatory and cannot use a cane or 
walker for mobility. The patient cannot functionally propel a manual wheelchair due to upper extremity 
weakness and impaired coordination. The patient cannot operate a power scooter due to impaired sitting 
balance and upper extremity strength. Our reviewer found that the patient requires a power wheelchair for 
mobility and accomplishing his daily activities. The patient has advanced seating requirements and requires a 
group 3 versus a group 2 power wheelchair. Our physician reviewer found that the patient has cervical spine 
myelopathy with upper and lower extremity weakness as well as spasticity. The patient cannot independently 
perform pressure relief and require power tilt and recline for pressure relief as well as power articulating leg 
rests for positioning and lower extremity spasticity. Our reviewer also found that the provided records in this 
case document the patient has undergone a specialty evaluation that confirms the individuals ability to safely 
operate the seat elevation equipment in the home. Records also document the patient performs 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 and they require a 
non-weight bearing transfer (for example, a dependent transfer) to/from the power wheelchair while in the 
home. 
 
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 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 options (K0861) and additional items and accessories (codes 
E2300, E2311, E2313, E2377, E0953, E0955, E0960, E1007, E1012, E1028, E2361, E2620, and E2622).  
 
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.