Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system (CPT Code E2300),
electronic connection between wheelchair controller and two or more power seating system motors, including
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
(E2311), expandable controller, including all related electronics and mounting hardware, upgrade provided at
initial issue (E2377), harness for upgrade to expandable controller, including all fasteners, connectors and
mounting hardware, each (E2313) and self-leveling cup holder, USB charger, LED light kit and Medical bag
hooks (K0108 X 4).
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied
your request. The Plan says the DME is not 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 the DME. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. 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 patient requires other types of proportional input devices (e.g., miniproportional
or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices
(e.g., sip and puff, head array, etc.) The patient 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 patient's upper extremity strength and function are sufficient for the patient to 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 the DME have not been met. Furthermore, the self-leveling cup holder, USB
charger, LED light kit and Medical bag hooks (K0108 X 4) do not serve a medical purpose and are not
covered. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system (CPT
Code E2300), electronic connection between wheelchair controller and two or more power seating system
motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed
mounting hardware (E2311), expandable controller, including all related electronics and mounting hardware,
upgrade provided at initial issue (E2377), harness for upgrade to expandable controller, including all fasteners,
connectors and mounting hardware, each (E2313) and self-leveling cup holder, USB charger, LED light kit and
Medical bag hooks (K0108 X 4).