Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair (K0861) and additional 
items and accessories (codes E0953, E0955, E0956, E2208, E2359, E2605, and K0108). We decided that the 
Plan does not have to pre-approve the additional items and accessories (codes E2311, E2377, E2313, E1012, 
and E1028).  
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E0953, E0955, E0956, E1012, E1028, E2208, E2311, E2359, E2605, and K0108). The Plan 
says that the enrollee does not have medical need for multiple power options included with a K0861 Group 3 
power wheelchair. The Plan also says that the electronic connection, expandable controller 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). 
 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair (K0861) and 
additional items and accessories (codes E0953, E0955, E0956, E2208, E2359, E2605, and K0108).  
 
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 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 
(K0861) and additional items and accessories (codes E0953, E0955, E0956, E1012, E2208, E2359, E2605, and 
K0108). Our physician reviewer found medical notes from a treating physician indicate the patient has a 
neurogenic bowel and bladder and neurogenic skin. Records from the treating physician indicate the need for 
every 2-hour turning while in bed and every 15-minute pressure relief/off-loading while sitting up. The 
patients upper extremity shoulder and elbow strength are rated as more than 2 out of 5 to 4 out of 5 with 0 out 
of 5 lower extremity strength. This does not support the patients ability to adequately perform pressure relief 
given their reported weight of 281 pounds. This documentation from the treating physician reports poor trunk 
control, core muscle weakness and does support that the patient is high risk for skin breakdown to require the 
Group 3 standard power wheelchair with multiple power options (K0861) including power tilt and recline 
(E1007). Our reviewer found that codes E0953, E0955, E0956, E1012, E2208, E2359, E2605, and K0108 are 
supported as the pad, headrest, supports and armrest are needed for positioning. The patient is on 2 liters of 
oxygen to support the need for the oxygen holder (E2208). Our physician reviewer also found that batteries 
(E2359) are necessary for the operation of the wheelchair. 
 
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 (K0861) and additional items and 
accessories (codes E0953, E0955, E0956, E1012, E2208, E2359, E2605, and K0108) have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 3 standard power wheelchair (K0861) and 
additional items and accessories (codes E0953, E0955, E0956, E2208, E2359, E2605, and K0108).  
 We also decided that the Plan does not have to pre-approve the additional items and accessories (codes 
E2311, E2377, E2313, E1012, and E1028). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
 
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 additional items and accessories 
(codes E2311, E2377, E2313, E1012, and E1028). Our physician reviewer found the power elevating leg rests 
(E1012) are not supported as the physician records do not document the patient has a musculoskeletal condition 
or the presence of a cast or brace which prevents 90-degree flexion at the knee, or the patient has significant 
edema of the lower extremities that requires a power elevating leg rest. Records do not support the necessity of 
the expandable controller, harness and electronic connection and swing away hardware (E2311, E2377, E2313, 
E1028) to control the power wheelchair's power options through a joystick. Our reviewer also found that the 
provided records document that the enrollee has 4 out of 5 to 5 out of 5 bilateral upper extremity hand and wrist 
strength and is supervision/set-up assist for grooming and feeding thus indicating the patient has adequate 
upper extremity strength and function to operate the wheelchairs power options with their own switches. 
 
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 additional items and accessories (codes E2311, E2377, E2313, E1012, and 
E1028) have not been met. Therefore, we decided that the Plan does not have to pre-approve the additional 
items and accessories (codes E2311, E2377, E2313, E1012, and E1028). 
 
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.