Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 standard power wheelchair with multiple power options, 
patient weight capacity up to and including 300 pounds (K0861), combination tilt and recline (E1007), center 
mount power elevating leg rest/platform (E1012), group 24 sealed lead acid battery (E2363), retractable or removable mounting hardware for joystick (E1028), power seat elevation system (E2300), electronic 
connection (E2311), harness (E2313), expandable controller (E2377), bag hook (K0108), lateral thigh or knee 
support (E0953), cushioned headrest (E0955), lateral trunk or hip support (E0956), shoulder harness/straps or 
chest strap (E0960), skin protection and positioning wheelchair seat cushion (E2607), and positioning 
wheelchair back cushion (E2620).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee requires 
the K0861 base and all recommended components to meet their mobility, medical, and functional needs in their 
home.  The Plan denied your request. The Plan says that the enrollee does not have medical need for multiple 
power options available with a K0861 group 3 power wheelchair. An expandable controller, harness, and 
electronics are not medically needed. The Plan also says that a bag hook (K0108) does not serve a medical 
purpose.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for mobility. The 
enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness and impaired 
shoulder range of motion. The enrollee cannot operate a power scooter due to impaired sitting balance and 
upper extremity strength. The enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. The enrollee has decreased upper extremity strength and reduced shoulder range of motion due to 
shoulder arthrodesis and cannot perform pressure relief. The enrollee therefore requires power tilt and recline 
for pressure relief. The enrollee also requires power elevating leg rests for positioning of their lower 
extremities. Given the enrollee's muscular dystrophy, complex seating needs, and the number of power 
components required, a group 3 power wheelchair is necessary and cannot be satisfied with a group 2 power 
wheelchair. Therefore, the group 3 power wheelchair with power tilt and recline and power elevating leg rests 
is medically necessary. This includes a group 3 standard power wheelchair with multiple power options, patient 
weight capacity up to and including 300 pounds (K0861), combination tilt and recline (E1007), center mount 
power elevating leg rest/platform (E1012), group 24 sealed lead acid battery (E2363), retractable or removable 
mounting hardware for joystick (E1028), power seat elevation system (E2300), electronic connection (E2311), 
harness (E2313), expandable controller (E2377), lateral thigh or knee support (E0953), cushioned headrest 
(E0955), lateral trunk or hip support (E0956), shoulder harness/straps or chest strap (E0960), skin protection 
and positioning wheelchair seat cushion (E2607), and positioning wheelchair back cushion (E2620). 
 
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 durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve a group 3 standard power wheelchair with multiple power options, patient 
weight capacity up to and including 300 pounds (K0861), combination tilt and recline (E1007), center mount 
power elevating leg rest/platform (E1012), group 24 sealed lead acid battery (E2363), retractable or removable 
mounting hardware for joystick (E1028), power seat elevation system (E2300), electronic connection (E2311), 
harness (E2313), expandable controller (E2377), bag hook (K0108), lateral thigh or knee support (E0953), 
cushioned headrest (E0955), lateral trunk or hip support (E0956), shoulder harness/straps or chest strap 
(E0960), skin protection and positioning wheelchair seat cushion (E2607), and positioning wheelchair back 
cushion (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.