Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve options and accessories for an approved power 
wheelchair (PWC), including an expandable controller (E2377) with related electronic connections (E2311) 
and harness (E2313), standard remote joystick (E2374), power seat elevation feature (E2300), arm pads 
(K0019), lateral positioning wedge (K0108), bracket footplates (K0108), attendant control (E2331), and a head 
control interface (E2330). 
 
You asked the Plan to pre-approve the requested PWC options/accessories. You say that the requested items 
should all be approved. The Plan denied your request. The Plan says the wheelchair itself and other 
components were approved. However, many of the denied codes are either noncovered, unbundled, or exceed 
the enrollee's medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that duplicative DME is not medically necessary. The rules also 
contain specific criteria for the individual components requested, as described in LCA A52504. 
 
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 expandable controller and related 
accessoires. Our reviewer says that the requested expandable controller and related accessories are not 
considered medically reasonable and necessary in this case. Our physician reviewer found here is no 
documentation that the expandable controller, harness and electronic connection at issue in this case meet 
Medicare criteria for medically reasonable and necessary. Provided records document that the enrollee has 4/5 
left upper extremity strength and left hand range of motion reported as 'within normal limits". As such, the 
enrollee is found to have adequate left upper extremity strength and range of motion to operate the wheelchair's 
power options with their own switches.  
 
This is an initial issue of the PWC. As such, coverage is not allowed for codes E2374 and K0019 as these are 
only payable for replacement, not at initial issue. The power seat elevator is also noncovered. Both lateral 
positioning wedges and bracket footplates have specific codes to describe them, meaning that they cannot be 
separately reported using code K0108. Since the PWC has been approved for a standard beneficiary-operated 
drive control, the attendant control and head control interface are considered duplicative and cannot be covered 
as well. 
 
We looked at our physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested PWC options/accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve options and accessories for an approved power wheelchair 
(PWC), including an expandable controller (E2377) with related electronic connections (E2311) and harness 
(E2313), standard remote joystick (E2374), power seat elevation feature (E2300), arm pads (K0019), lateral 
positioning wedge (K0108), bracket footplates (K0108), attendant control (E2331), and a head control interface 
(E2330).