Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311). We decided that the Plan does not have to pre-approve a joystick remote 
(K0108), a shroud and a power seat elevation system (E2300).  
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection for a power 
wheelchair, as well as a joystick remote, a shroud and a power seat elevation system. You say that the 
requested items are a medical necessity for the enrollee. The Plan says that medical-necessity rules for the 
requested items have not been met. 
 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic 
connection.  
 
The Plan follows Medicare rules. The rules say that an expandable controller with harness and electronic 
connection provide the functions listed in the Medicare rules section of this letter. 
 
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 with harness 
and electronic connection. Our reviewer says that an expandable controller with harness and electronic 
connection is medically reasonable and necessary in this case. Our physician reviewer found that the clinical documentation shows that there are 3 power options and the enrollee has significant range-of-motion (ROM) 
impairments in upper limbs and chronic pain syndrome. The enrollee would therefore not be expected to be 
able to use the individual power switches consistently.  
 
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 with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311). 
 
We also decided that the Plan does not have to pre-approve a joystick remote, a shroud and a power seat 
elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because 
it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of 
a power seat elevation system have not been met. 
 
The Medicare rules also say that Medicare will pay for durable medical equipment that is mainly used to serve 
a medical purpose and that code K0108 must not be used for any component or feature of an expandable 
controller at the time of initial issue. In this case, a shroud does not serve a primarily medical purpose. A 
joystick remote is a component of an expandable controller and harness. Based on this information, we decided 
that Medicare rules for coverage of a joystick remote and a shroud have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a joystick remote (K0108), a shroud and a power seat elevation 
system (E2300). 
 
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.