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, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E1012, E0953, E0955, E1007, E1028, E2209, E2300, E2331, E2361, 
E2605, E2620, K0040, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the physician as well as the therapist have documented thoroughly why this is needed for the 
enrollee. You also say that the equipment is prudent and necessary to improve and ultimately maintain the 
enrollee's quality of health. The Plan denied your request. The Plan says the enrollee does not have medical 
need for multiple power options included with K0861 group 3 power wheelchair. An electronic connection, 
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). The Plan also says that power elevating leg rests 
are not medically needed. 
 
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 the PWC base is not covered, then related accessories will be denied. 
 
 
 
 
 
 
 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 
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 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. There is inadequate clinical documentation regarding why the enrollee 
requires power tilt and recline and cannot perform pressure relief. Our reviewer found that the enrollee has no 
history of skin breakdown and can perform transfers with a slide board with contact guard assistance. There is 
no significant lower extremity edema or spasticity that would require power elevating leg rests. Our physician 
reviewer also found that it is not clear why the enrollee requires a power seat elevator and if this would allow 
them to independently transfer without supervision or contact guard assistance. While the enrollee has a history 
of stroke, they are still noted to have 4 out of 5 motor strength in their unaffected upper and lower extremities. 
A Group 3 power wheelchair base is indicated for patients with total paralysis, such as with spinal cord injury 
or muscular dystrophy. 
 
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 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, patient weight capacity up to and including 300 pounds (K0861) and 
additional items and accessories (codes E2311, E2313, E2377, E1012, E0953, E0955, E1007, E1028, E2209, 
E2300, E2331, E2361, E2605, E2620, K0040, and K0108).