Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 PWC, power tilt and recline with the standard 
accessories included with a group 3 power wheelchair. We decided that the Plan does not have to pre-
approve unbundled accessories not included with the group 3 PWC and expandable controller or associated 
electronics..  
 
You asked the Plan to pre-approve a Group 3 power wheelchair PWC (K0861) with multiple power options 
and accessories (E0956, E1012, E0955, E1029, E2363, E1028 (x4), E2377, E2313, E2300, E1007 and E2311).. 
You say that the provider is appealing with supporting records. The Plan says that it is not well documented 
that the enrollee would be able to adequately control and operate the power wheelchair given dementia/memory 
loss documented. The Plan states a manual wheelchair with attendant/caregiver control might be more 
appropriate. 
 
We decided that the Plan has to pre-approve a group 3 PWC, power tilt and recline with the standard 
accessories included with a group 3 power wheelchair.  
 
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 the durable medical equipment (DME). 
Our reviewer says the enrollee is ventilator dependent. The enrollee has a degenerative neurological disease. 
The enrollee meets criteria for power tilt and recline with the standard accessories included with a group 3 
power wheelchair. The Plan's denial of the enrollee's inability to manage a power wheelchair are not supported 
in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve a group 3 PWC, power tilt and recline with the standard accessories included 
with a group 3 power wheelchair.  
 
We also decided that the Plan does not have to pre-approve unbundled accessories not included with the 
group 3 PWC and expandable controller or associated electronics.. 
 
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 unbundled accessories not included 
with the group 3 and expandable controller or associated electronics. Our reviewer says that unbundled 
accessories not included with the group 3 are not medically necessary. The enrollee has adequate strength to 
manage standard power drives and does not require an expandable controller, or associated electronics.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of unbundled accessories not included with the group 3 and expandable controller 
or associated electronics. have not been met. Therefore, we decided that the Plan does not have to pre-approve 
unbundled accessories not included with the group 3 PWC and expandable controller or associated electronics.. 
 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.