Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), electronic connection 
(E2311), and harness (E2313). We decided that the Plan does not have to pre-approve a power seat elevation 
system (E2300) and bag hooks (K0108).  
 
You asked the Plan to pre-approve a power seat elevation system (E2300), expandable controller (E2377), 
electronic connection (E2311), harness (E2313), and bag hooks (K0108). You say that the items are medically 
necessary.  The Plan says that the items are not medically necessary. 
 
We decided that the Plan has to pre-approve an expandable controller (E2377), electronic connection 
(E2311), and harness (E2313).  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. 
 
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 power wheelchair features and 
accessories. Our reviewer says that [state physician reviewer's conclusion these items are medically necessary. 
Our physician reviewer found that the enrollee cannot perform pressure relief independently due to weakness 
of their proximal upper extremities and requires a power wheelchair with power tilt and recline for adequate 
pressure relief and positioning. The complexity of the enrollees seating and positioning needs necessitates a 
more complex group 3 power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the power tilt and recline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377), electronic connection 
(E2311), and harness (E2313).  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and 
bag hooks (K0108). 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that 
is mainly used to serve a medical purpose 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seat elevation system and bag hooks do not serve a purpose that is primarily medical in nature. 
These items are 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 a power seat elevation system (E2300) and 
bag hooks (K0108). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.