Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, expandable controller harness, LED light kit, transfer handles and power seat elevation feature.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that these items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code K0108 is wheelchair component or accessory, not otherwise specified. We find that CPT code K0108 (transfer handles) is not supported in the medical record. Specifically transfer handles are more appropriately coded at E0705 (Transfer device, any type). Based on this information, we decided that Medicare rules for coverage of transfer handles has not been met. Therefore, we decided that the Plan does not have to pre-approve transfer handles.
Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature.
The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The LED light kit does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the LED light kit.
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 electronic connection, expandable controller and expandable controller harness. Our reviewer says that the electronic connection, expandable controller and expandable controller harness are not considered medically reasonable and necessary in this case. The documentation does not indicate that you require a proportional input devices other than a standard proportional joystick or a non-proportional input device. You do not need to operate three or more powered seating actuators through the drive control. You do not need an expandable controller to be able to operate one or more of the following: a separate display; other electronic devices or an attendant control. The documentation indicates you have sufficient strength to control the power features through their own individual switches. Our physician reviewer found that your condition does not meet criteria for coverage of the electronic connection, expandable controller and expandable controller harness. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection, expandable controller or expandable controller harness.