Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair with multiple power options 
(K0861) and related accessories and features, except for the accessories and features specifically indicated 
below as denied. We decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311), a Q-Logic expandable joystick (K0108) and a manual 
swingaway feature (E1028), a footplate width extension (K0108), a center mount power-elevating platform 
(E1012) and an incontinence cover for a wheelchair seat cushion (K0108).  
 You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options (K0861) 
and related accessories and features. You say that the requested items are a medical necessity for the enrollee. 
The Plan says that the requested items are not medically necessary. 
 
We decided that the Plan has to pre-approve a Group 3 standard power wheelchair with multiple power 
options (K0861) and related accessories and features, except for the accessories and features specifically 
indicated below as denied.  
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair (PWC) with multiple power 
options is covered when the criteria listed in the Medicare rules section are met. 
 
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 items at issue. Our reviewer says 
that a Group 3 power wheelchair is medically reasonable and necessary in this case. Our physician reviewer 
found that there is documentation that the enrollee has a personal mobility deficit that impairs participation in 
MRADLs, such as toileting, feeding, grooming and bathing in customary locations within the home. The 
mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to the enrollee's level 
of weakness. The enrollee can safely operate a power mobility device. The enrollee's mobility limitation is due 
to a neurological condition. The enrollee meets coverage criteria for a power tilt and recline seating system 
because the provided records document a history of a stage III pressure injury of the sacrum/coccyx with an 
inability to perform a functional weight shift. Records also document increased tone in the trunk and lower 
extremities. The provided records document the necessity of: the skin protection and positioning cushion 
(E2607) and the positioning back cushion (E2620) due to a history of pressure injury; the adjustable-angle 
footplate (K0040) due to ankle weakness; the lateral thigh or knee support 9E0953) due to lower-extremity 
weakness; the cushioned headrest 9E0955) due to the tilt/recline feature; the lateral trunk or hip support 
(E0956) due to trunk weakness; and of the lead acid battery (E2361), as this is needed for the power wheelchair 
operation. 
 
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 standard power wheelchair with multiple power options (K0861) and related 
accessories and features, except for the accessories and features specifically indicated below as denied.  
 
We also decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311), a Q-Logic expandable joystick (K0108) and a 
manual swingaway feature (E1028), a footplate width extension (K0108), a center mount power-elevating 
platform (E1012) and an incontinence cover for a wheelchair seat cushion (K0108). 
 
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 items at issue. Our reviewer says 
that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found 
that an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) is not medically 
necessary. The provided records document that the enrollee has 3+/5 to 4-/5 upper extremity wrist strength and 
good to fair grip strength, thus indicating the enrollee has adequate upper-extremity strength and function to 
operate the wheelchair's power options with their own switches. The provided medical records do not support 
the medical necessity of the Q-Logic expandable joystick (K0108), the manual swingaway feature (E1028) or 
the footplate width extension (K0108). A center mount power-elevating platform (E1012) is not medically 
necessary. Provided records do not document that the enrollee has a musculoskeletal condition or the presence 
of a cast or brace which prevents 90-degree flexion at the knee, or that the enrollee has significant edema of the lower extremities that requires a power-elevating platform. 
 
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 items at issue have not been met. 
 
Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-
reusable. While an incontinence cover for a wheelchair seat cushion (K0108) may be appropriate in this case, 
neither the Plan nor Medicare offers coverage of this item. 
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311), a Q-Logic expandable joystick (K0108) and a manual 
swingaway feature (E1028), a footplate width extension (K0108), a center mount power-elevating platform 
(E1012) and an incontinence cover for a wheelchair seat cushion (K0108). 
 
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.