Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options (K0861) 
with power tilt/recline and all other accessories. We decided that the Plan does not have to pre-approve the 
expandable controller (E2377), harness (E2313), electronic connection (E2311), special joystick handle 
(E2323) and power elevating leg rests (E1012).  
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (tilt/recline, 
legrests), and accessories. You say that the enrollee has difficulties both with upper extremity weakness and 
lower extremity weakness that preclude a self-propelled device. You say that tilt is necessary to relieve 
pressure from sacral area and elevate their lower extremities to help reduce swelling. You also say that this type 
of chair would make it easier to get in and out of bed. The Plan says that the notes do not show a medical need 
for the requested multiple power options. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options 
(K0861) with power tilt/recline and all other accessories.  
 
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 item/service at issue. Our reviewer 
says that the provided records document the enrollee has spasticity to meet criteria for the power tilt and/or 
recline and thus the multiple power option base and all of the requested accessories except the expandable 
controller (E2377), harness (E2313), electronic connection (E2311), special joystick handle (E2323) and power 
elevating leg rests (E1012). 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve a group 3 power wheelchair with multiple power options (K0861) with power tilt/recline and all 
other accessories.  
 
We also decided that the Plan does not have to pre-approve the expandable controller (E2377), harness 
(E2313), electronic connection (E2311), special joystick handle (E2323) and power elevating leg rests 
(E1012). 
 
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 item/service at issue. Our reviewer 
says that the provided records document that the enrollee has 4/5 to 4+/5 upper extremity strength and is 
supervision/set-up assist with eating and grooming thus indicating he has adequate upper extremity strength 
and function to operate the wheelchair's power options with their own switches with no need to control the 
power wheelchair's power options through a joystick. The provided records do not document the enrollee has a 
musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee, or 
the enrollee has significant edema of the lower extremities that requires a power elevating leg rest. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller (E2377), harness (E2313), electronic connection 
(E2311), special joystick handle (E2323) and power elevating leg rests (E1012). 
 
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.