Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options, patient weight capacity up to and including 300 pounds (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), general use wheelchair seat cushion (E2601), positioning wheelchair 
back cushion (E2620), adjustable angle footplate (K0040), privacy flap for seat widths of 16" - 20" (K0108), 
flip back armrests (K0108), short bracket 13" x 15" lower leg length (K0108). 
 
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 has a mobility deficit which cannot be improved, 
they are unable to ambulate, and have general deconditioning. You also say that the enrollee currently has a 
wheelchair they use, but you are not sure how much longer they will be able to use it because it is falling apart. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with K0861 group 3 power wheelchair. The Plan also says it is not medically necessary to 
control the requested electronic connection (E2311), harness (E2313), expandable controller (E2377) through 
the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 and additional items and accessories. Our reviewer says that a group 3 standard 
power wheelchair with multiple power options and additional items and accessories are not medically 
reasonable and necessary. Our physician reviewer found the enrollee has a neurologic disorder with functional 
deficits. The documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or has spasticity that would necessitate power tilt or recline. Our reviewer also 
found that although the enrollees condition may meet criteria for a PWC, the criteria for this specifically 
requested PWC with multiple power options including power tilt and recline are not met. 
 
 
 
 
 
 
 
 
 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 not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options, patient weight capacity up to and 
including 300 pounds (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), general use 
wheelchair seat cushion (E2601), positioning wheelchair back cushion (E2620), adjustable angle footplate 
(K0040), privacy flap for seat widths of 16" - 20" (K0108), flip back armrests (K0108), short bracket 13" x 15" 
lower leg length (K0108).