Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power elevating leg rests (E1012), power seat 
elevation system (E2300), expandable controller (E2377) with related electronic connections (E2311) and 
harness (E2313), and a backpack holder (K0108) for use with an approved power wheelchair (PWC). 
 
You asked the Plan to pre-approve the additional components and accessories for the PWC. You say that these 
items should be approved. The Plan denied your request. The Plan says all medically reasonable components 
were approved. The denied items exceed the medical need or are not eligible for Medicare coverage. 
The Plan follows Medicare rules. Medicare rules say that only medically reasonable and necessary items and 
services may 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 the additional components and 
accessories for the PWC. Our reviewer says that the documentation does not support that the expandable 
controller, or the power elevating leg rests are medically reasonable and necessary for use with this PWC. Our 
physician reviewer found the documentation does not reveal that the patient has leg edema, contractures in the 
lower extremities, inability to flex her knees, or requires this to be used with the approved power tilt feature. 
The documentation states that "in the prior evaluation the provider and patient discussed it and decided not to 
pursue power leg rests."  The provider notes that "After evaluating and considering further the patient would 
like that feature to assist with transfers, augmented positioning for contracture management, and will work with 
power tilt to help edema management and positioning." The physician documentation does not reveal evidence 
of contractures, edema, or how this feature will improve patient's transferring ability. She is supervision level 
for transfers and needs help only when fatigued. The patient is able to sit upright without support. The 
requested power leg rests exceed her medical need. 
 
The patient has one power option of power tilt on the approved wheelchair. The patient's upper extremity 
strength and function support that the patient can control any power options through their own switches. As 
such, the expandable controller also exceeds the enrollee's medical need. 
 
The rules also indicate that only items with a primarily medical purpose may be covered. A backpack holder 
does not primarily address a medical condition. A power seat elevator is also not considered primarily medical 
in nature. 
 
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 additional components and accessories for the PWC have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the power elevating leg rests (E1012), power 
seat elevation system (E2300), expandable controller (E2377) with related electronic connections (E2311) and 
harness (E2313), and a backpack holder (K0108) for use with an approved power wheelchair (PWC).