Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat elevator (E2300), an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through a joystick.You asked the Plan to pre-approvea seat elevator, an expandable controller, an expandable controller harness, and a electro connect. You say that the requested seat elevator (E2300), 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 seat elevator (E2300), 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 a seat elevator, an expandable controller, an expandable controller harness, and an electro connect. 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 memberhas diagnoses that include post-polio syndrome, chronic pain, myofascial pain, bilateral leg and shoulder pain, abnormal gait, and arthralgia of the legs. She was seen for a seating and mobility evaluation on 10/16/2019. She had pain aggravated with sitting, standing, and walking. She was wheelchair dependent and was only using crutches to access the bathroom. She was being seen for a new power wheelchair. She had received her current power wheelchair in September 2003. Her legs were weaker and she had fallen 3 times in 1 week. DME included a transport van with side entry left. She was able to transfer to the driver seat. She was able to drive without hand controls and had remaining strength in her right foot. Physical examination findings included normalupper extremity muscle tone. Her range of motion was impaired by pain. She had strength graded at 3/5. She had slowness of dexterity of the upper extremities. In the lower extremities she had strength graded at 3/5 or less. Her left straight leg was shorter than the right. There was impaired left lower extremity coordination/dexterity. She had a posterior pelvic tilt with obliquity. She was able to maintain her seated balance without assistance. She was independent in performing a lateral transfer from a level surface. Recommendations included a Group 3 power wheelchair. A Group 3 power wheelchair was approved. The member does not meet criteria for the accessories at issue. She has she is able to operate a vehicle without use of hand controls and would beexpected to operate the additional features of her power wheelchair using the standard switches supplied. These accessories are not medically reasonable or necessary for the member to be able to operate her new wheelchair.Furthermore, a seat elevation feature (E2300) is non-covered because it is not primarily medical in nature.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 seat elevator, an expandable controller, an expandable controller harness, and a electro connect have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat elevator (E2300), an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through a joystick.