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 
(K0861), electronic connection (E2311), harness (E2313), expandable controller (E2377), and additional items 
and accessories (codes E0953, E0955, E1007, E1012, E1028, E2359, E2613, E2622, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you cannot pay for the wheelchair yourself, which is why you are requesting it through the 
insurance company. The Plan denied your request. The Plan says that you do not have a medical need for 
multiple power options included with K0861 group 3 power wheelchair. 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 power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (MRADLs), the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the 
patient is not 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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. 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 contracture. You cannot operate a power scooter due to impaired upper 
extremity strength and inability to transfer. Our reviewer found that you require a power wheelchair for 
mobility and accomplishing your daily activities. You require a group 3 power wheelchair given your 
neurological condition of stroke with hemiplegia and contracture. You are unable to independently perform 
pressure relief and require a seating system with power tilt and recline. You require power elevating leg rests 
for positioning and your lower extremity spasticity and contracture. Our physician reviewer also found that a 
group 2 power wheelchair would not suffice given your seating needs. 
 
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 options (K0861), electronic connection (E2311), harness (E2313), expandable controller 
(E2377), and additional items and accessories (codes E0953, E0955, E1007, E1012, E1028, E2359, E2613, 
E2622, and K0108).  
 
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.