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 (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1028, E2300, E2323, E2363 x2, E2607, E2620, and K0108 x2). 
 
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 expandable controller and harness are not an integral part of 
the base, thus a split decision should be possible. The Plan denied your request. The Plan says the enrollee does 
not have medical need for multiple power options included with a 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 the PWC base is not covered, then related accessories will be denied. 
 
 
  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 the group 3 power 
wheelchair with power tilt and recline and power seat elevator is not medically necessary. Our physician 
reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility. The 
enrollee cannot functionally propel a manual wheelchair due to impaired positioning. The enrollee cannot 
operate a power scooter given that they are dependent for transfers. Our reviewer found that the enrollee 
requires a power wheelchair for mobility and accomplishing their daily activities. However, the clinical 
documentation is insufficient why a lower-level power wheelchair would not suffice for the enrollee's needs 
versus a group 3 power wheelchair. There is inadequate clinical documentation regarding why the enrollee 
requires power tilt and recline and cannot perform pressure relief. Our physician reviewer found that the 
enrollee has no history of skin breakdown, their sensation is intact, and they are noted to be independent with 
pressure relief. There is also no significant lower extremity edema or spasticity. It is unclear why the enrollee 
requires positioning for spasticity since Ankylosing Spondylitis is not a neuromuscular disease. Our reviewer 
also found that the enrollee is dependent with transfers and does not require a power seat elevator. 
 
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 (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E0955, E1007, E1028, E2300, E2323, E2363 x2, E2607, E2620, and 
K0108 x2).