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 E2311, E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Medicare criteria. 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 upper extremities with the ability to be independent in feeding 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.