Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 standard power wheelchair with multiple power option 
(K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E0956 x4, E1007, E1012, 
E1028 x6, E2300, E2363 x2, E2607, and E2620). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the K0861 base and all recommended components are needed to meet the enrollee's current 
medical, mobility, and functional needs. The Plan denied your request. 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 the electronic connection, harness, 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 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. 
 
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 & 
recline, power seat elevator and power articulating foot platform is medically necessary. Our physician 
reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility. They 
cannot functionally propel a manual wheelchair due to upper extremity weakness. Our reviewer found that the 
enrollee requires a power wheelchair for mobility and accomplishing their daily activities. The enrollee has a 
progressive neuromuscular disease. They are unable to functionally perform weight shifts and requires power 
tilt and recline for adequate pressure relief. The enrollee requires power articulating footrests for position and 
reduction of edema given their heart failure. Our physician reviewer also found that the enrollee requires the 
power elevator for assistance with transfers and to improve their ability to perform daily activities. 
 
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 
been met. Therefore, we decided that the Plan has to pre-approve a group 3 standard power wheelchair with 
multiple power option (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, 
E0956 x4, E1007, E1012, E1028 x6, E2300, E2363 x2, E2607, and E2620).  
 
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.