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), Biofit Replacement Incontinence Cover (K0108), and RNET Dongle and PC Programmer Kit (K0108).
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, Biofit Replacement Incontinence Cover, and RNET Dongle and PC Programmer Kit. 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 power wheelchair accessories are covered when specific criteria is met. 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, Biofit Replacement Incontinence Cover, and RNET Dongle and PC Programmer Kit. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that you require 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.).
You do 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. Your strength and functional abilities are sufficient to control any power options through your own individual switches. A separate request for a replacement cover for the approved seat cushion is not medically necessary. The replacement cushion is not medically necessary as the approved cushion comes with a cover. Additionally, the K0108 RNET Dongle and PC Programmer Kit cannot be approved. K0108 RNET Dongle and PC Programmer Kit is already included in E2377 Expandable Controller and is not medically necessary. These items would exceed your medical need. 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, Biofit Replacement Incontinence Cover, and RNET Dongle and PC Programmer Kit 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), Biofit Replacement Incontinence Cover (K0108), and RNET Dongle and PC Programmer Kit (K0108).