Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller E2377) harness (E2313) electronic connection (E2311) power seat elevation feature (E2300) power standing feature (E2301) and other accessories-medical necessities bag hooks (K0108) other accessories-black mesh cushion-corpus ergo back (K0108), other accessories-modify foot plate width (K0108).
You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee's current chair is breaking down and needs replacing. The Plan denied your request. The Plan says the expandable controller, harness and electronic connection are not medically necessary. The power seat elevation feature and power standing feature are not primarily medical items and the medical necessities bag hooks is a convenience item. The plan also says that the black mesh cushion- corpus ergo back is coded incorrectly and cannot be billed separately and the foot plate is miscoded.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee requires a proportional input device, other than a standard proportional joystick, a non-proportional input device. The enrollee does not need to operate 3 or more powered seating actuators through the joystick. The enrollee does not need an expandable controller to be able to operate one or more of the following: a separate, other electronic devices or an attendant control. The documentation indicates the enrollee has sufficient strength and functional ability to control the power features through their own individual switches therefore the requested electronic connection, expandable controller and expandable controller harness are not medically necessary. The request for a power seat elevation feature and power standing feature cannot be considered a medical necessity per Medicare as they are not purely medical in nature. The bag hooks are not medically necessary per Medicare as they would be considered a convenience item. The black mesh cushion does not meet Medicare medical necessity criteria as this item is already included in the approved wheelchair and an additional black mesh cushion would exceed the patient's needs and the modified foot plate width is already included in the code for the approved power Group 3 wheelchair. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller E2377) harness (E2313) electronic connection (E2311) power seat elevation feature (E2300) power standing feature (E2301) and other accessories-medical necessities bag hooks (K0108) other accessories-black mesh cushion-corpus ergo back (K0108), other accessories-modify foot plate width (K0108).