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) with additional items and accessories (codes E1002, E1012, E2361, E1028, E2311, E2313, 
E2377, K0108, E0955, E0956, E2608, and E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with additional items and accessories. 
You say that the enrollee is willing and able to safely use the recommended equipment, and it is the least costly 
and most appropriate in their home environment. The Plan denied your request. The Plan says the enrollee does 
not have medical need for single power option included with K0856 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with power seating 
system, tilt only, may be covered if certain criteria 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 
with additional items and accessories. Our reviewer says that the Group 3 power wheelchair with power tilt and 
power elevating leg rests is not medically necessary. Our physician reviewer found the enrollee is functionally 
non-ambulatory given their Parkinsons Disease and cannot use a cane or walker for mobility. The enrollee 
cannot functionally propel a manual wheelchair due to upper extremity weakness and lack of coordination. The 
enrollee cannot operate a power scooter due to impaired sitting balance and inability to independently transfer. 
Our reviewer found that 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 the enrollee's needs versus a group 3 power wheelchair. There is inadequate clinical documentation 
regarding why the enrollee requires power tilt and cannot perform pressure relief. Our physician reviewer 
found that the enrollee has no history of skin breakdown and has 3 out of 5 motor strength in the upper 
extremities. The enrollee is also noted to have 2+ lower extremity edema, but it is unclear how this was 
determined given that the evaluation was performed virtually and not in person. Our reviewer also found that 
here is also no history of lymphedema and therefore it is unclear why he would require power elevating leg 
rests. Group 3 power wheelchairs are typically indicated for patients with total paralysis, such as with 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 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) with additional items and accessories (codes E1002, E1012, 
E2361, E1028, E2311, E2313, E2377, K0108, E0955, E0956, E2608, and E2620).