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), cushioned headrest (E0955), skin protection wheelchair seat cushion (E2622), 
combination tilt and recline (E1007), center mount power elevating leg rest/platform (E1012), group 34 sealed 
lead acid battery (E2359), retractable or removable mounting hardware for joystick (E1028), power seat 
elevation system (E2300), electronic connection (E2311), harness (E2313), and expandable controller (E2377). 
 
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 requires multiple seat functions for multiple reasons. 
You also say that the enrollee has limited assistance at home, and elevation of the wheelchair would allow them 
to transfer independently. The Plan denied your request. The Plan says the enrollee does not have medical need 
for multiple power options available with K0861 group 3 power wheelchair. The Plan says an expandable 
controller, harness, and electronics are not medically needed. The Plan also says a seat elevator does not serve a 
medical purpose and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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 the group 3 power 
wheelchair with power tilt and recline, power seat elevator, and power elevating leg rests is not medically 
necessary. Our physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for 
mobility. The enrollee currently uses a power wheelchair for mobility which requires replacement due to not 
functioning properly. Our reviewer found that there is limited information provided regarding his level of 
function with specific daily activities and no graded motor strength examination, but the enrollee appears to be 
unable to functionally propel a manual wheelchair or operate a power scooter. The enrollee likely 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 their needs versus a group 3 power 
wheelchair with power tilt and recline and power seat lift. Our physician reviewer found there is inadequate 
clinical documentation regarding why the enrollee requires power tilt and recline and cannot perform pressure 
relief. The enrollee has no history of skin breakdown and has intact sensation. Our reviewer found that the 
enrollee can independently transfer and has at least fair strength in the upper extremities. The enrollee can 
independently transfer and therefore does not require a power seat elevator. Our physician reviewer also found 
that the enrollee also does not have lower extremity spasticity or significant edema and therefore does not 
require power elevating leg rests. 
 
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), cushioned headrest 
(E0955), skin protection wheelchair seat cushion (E2622), combination tilt and recline (E1007), center mount 
power elevating leg rest/platform (E1012), group 34 sealed lead acid battery (E2359), retractable or removable 
mounting hardware for joystick (E1028), power seat elevation system (E2300), electronic connection (E2311), 
harness (E2313), and expandable controller (E2377).