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 E2311, E2313, E2377, E0955, E1007, E1012, E1028, 
E2361, and E2603). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee clinically qualifies for and medically meets criteria for a Group 2 power wheelchair 
with power tilt because they are unable to perform independent, effective weight shifts and are at high risk for 
pressure ulcers. You also say that you would like the documentation provided to be reconsidered for the K0835 
base and all recommended components needed to meet the enrollee's current medical, mobility and functional 
needs. The Plan denied your request. The Plan says that the enrollee does not have medical need for multiple 
power options included with K0842 group 2 power wheelchair with multiple power options. 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 must follow Medicare rules. Medicare rules say that a Group 3 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 
and additional items and accessories. Our reviewer says that the group 2 power wheelchair with power tilt and 
recline and power elevating leg rests is medically necessary. Our physician reviewer found the enrollee is non-
ambulatory and cannot use a cane or walker for mobility. They cannot functionally propel a manual wheelchair 
due to upper extremity weakness and lymphedema and wounds. The enrollee cannot operate a power scooter 
due to impaired ability to transfer upper extremity strength. Our reviewer found that the enrollee requires a 
power wheelchair for mobility and accomplishing their daily activities. The enrollee requires power elevating 
leg rests given their lower extremity edema and wounds. Our physician reviewer also found that the enrollee 
requires power tilt and recline given that they cannot independently preform pressure relief due to upper 
extremity weakness, wounds and edema. 
 
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 options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, 
E1007, E1012, E1028, E2361, and E2603).  
 
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.