Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with multiple 
power option (K0842) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, and E2604). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair and additional items and accessories. 
You say that the patient cannot complete independent mobility related activities of daily living within their 
home without the use of a power wheelchair. You also say that the documentation provided does document a 
thorough need for powered mobility within the home, and you would like this chair to be approved. The Plan 
denied your request. The Plan says the patient does not have medical need for multiple power options included 
with a K0842 Group 2 power wheelchair with multiple power options. The Plan also says an electronic 
connection, expandable controller, and expandable controller harness 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 2 Multiple Power Option PWC (such as code 
K0842) is covered if all the basic coverage criteria for a power wheelchair (PWC) are met and 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 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the patient is noted to be able to ambulate with a cane or walker but has difficulty 
doing so. There is a lack of documentation indicating the patients level of mobility. They are noted to not be 
able to propel a manual wheelchair due to reduced shoulder range of motion but there is not physical 
examination documentation provided in terms of the degrees of range of motion and the etiology of the 
patients shoulder condition. Our reviewer found that the patient is noted to have skin breakdown on the 
buttock, but there is no clinical documentation regarding the staging and degree of a pressure wound. The 
physical examination indicates that the patients skin is intact. Our physician reviewer also found that the 
documentation does not support why the patient cannot adequately perform pressure relief or propel a manual 
wheelchair for mobility and performing 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 2 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 2 standard power 
wheelchair with multiple power option (K0842) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, and E2604).