Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness for upgrade 
to expandable controller (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), and calf panels. 
 
You asked the Plan to pre-approve an expandable controller, a harness for upgrade to expandable controller, 
electronic connection between wheelchair controller and two or more power seating system motors, and calf 
panels. You say that the items are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for wheelchair options 
and accessories to be 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, a harness for 
upgrade to expandable controller, electronic connection between wheelchair controller and two or more power 
seating system motors, and calf panels. Our reviewer says that the items are not medically necessary. Our 
physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not 
medically necessary. 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 upper limb strength and function are currently able to use a 
standard joystick and therefore should be sufficient to control any power options with their individual switches. 
The calf pad is not medically necessary as it is already included in the approved power wheelchair and would 
exceed the enrollee's medical need. Per Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k),  
the requested calf pad is not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. 

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, a harness for upgrade to expandable controller, 
electronic connection between wheelchair controller and two or more power seating system motors, and calf 
panels have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable 
controller (E2377), a harness for upgrade to expandable controller (E2313), electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), and calf panels.