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), electronic connection (E2311), harness (E2313), expandable controller (E2377), and additional items 
and accessories (codes E0955, E1007, E1012, E1028, E2359, E2607, E2611, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options, 
electronic connection, harness, expandable controller, and additional items and accessories. You say that you 
would like the denial to be reconsidered and the power wheelchair with a power tilt and recline seating system 
to be approved for the enrollee so they can have the appropriate medical equipment to meet their medical 
needs. 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 an 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 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, electronic connection, harness, expandable controller, and additional items and 
accessories. Our reviewer says that the group 3 power wheelchair with power tilt and recline is medically 
necessary. 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. 
The patient cannot operate a power scooter due to impaired sitting balance and upper extremity strength. Our 
reviewer found that the enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. The enrollee has significantly impaired sitting balance and cannot adequately perform pressure relief 
due to bilateral upper extremity weakness. The enrollee has impaired sensation and is at risk for skin 
breakdown given their stroke. Our physician reviewer also found that a lower-level power wheelchair such as a 
group 2 power wheelchair would not meet the enrollee's complex seating needs and therefore, they require a 
group 3 power wheelchair power tilt and recline. 
 
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, electronic connection, harness, expandable 
controller, 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), electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and additional items and accessories (codes E0955, 
E1007, E1012, E1028, E2359, E2607, E2611, 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.