Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick. 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. 
You say that the requested expandable controller (E2377), expandable controller harness (E2313), and electro 
connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are medically 
necessary. The Plan denied your request. The Plan says the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are not medically necessary. 
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick. Our reviewer says that the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are not medically necessary. Our physician reviewer found the E2377 
Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local 
Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not 
reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive 
control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. The 
enrollee's strength and function in the right upper extremity with the ability to feed herself supports that the 
enrollee can control any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick.