Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, E2607, E2620, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee requires the medically justified complex power wheelchair with tilt, recline, power 
elevating leg rests necessary electronics, and a pressure relieving and positioning cushion. The Plan denied 
your request. The Plan says 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, 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 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. 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 3 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 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 
meet the enrollees needs versus a group 3 power wheelchair. Our reviewer found that there is inadequate 
clinical documentation regarding why they require power tilt and recline and cannot adequately perform 
pressure relief. A history of skin breakdown is noted but there is no information regarding where and to what 
extent this occurred. The enrollee requires assistance with daily activities, but the level of assistance is not 
specified as well as the need for assistance with transfers. Our physician reviewer also found that there is no 
significant lower extremity spasticity that would necessitate a power elevating foot platform. A group 3 power 
wheelchair base is typically indicated in patients with significant paralysis due to conditions such as a 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 and 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 multiple power option (K0861) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, and K0108).