Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) OR group 3 standard power wheelchair with multiple power options (K0861), and additional 
items and accessories (codes E0955, E1007, E1028, E2311, E2361, E2605, and E1028). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option, or group 3 
standard power wheelchair with multiple power options, and additional items and accessories. You say that you 
are resubmitting for a power wheelchair with tilt and articulating foot platform. The Plan denied your request. 
The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for which a Group 
3 power wheelchair is medically needed. The Plan also says there is no medical need for multiple power 
options included with a Group 3 PWC K0861 base. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with Single 
Power Option (such as code K0856) or 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 
with single power option, or group 3 standard power wheelchair with multiple power options, and additional 
items and accessories. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for mobility. They cannot 
functionally propel a manual wheelchair due to upper extremity shoulder pain and limitation with range of 
motion. 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 meet the 
enrollees needs versus a group 3 power wheelchair. Our reviewer found that there is inadequate clinical 
documentation regarding why they require power tilt and recline and cannot adequately perform pressure relief. 
The enrollee is being monitored for possible skin breakdown, but it is not clear where and to what extent the 
enrollee has skin breakdown. Our physician reviewer found that additionally, the enrollee has nearly full motor 
strength in the upper extremities and is essentially independent with their daily activities. A group 3 power 
wheelchair base is typically indicated in patients with significant paralysis due to conditions such as a spinal 
cord injury. 
 
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 with single power option, or group 3 
standard power wheelchair with multiple power options, 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 single power option (K0856) OR group 3 standard power wheelchair with multiple power options 
(K0861), and additional items and accessories (codes E0955, E1007, E1028, E2311, E2361, E2605, and 
E1028).