Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  power seat elevation system (E2300) enhanced steering 
perform unit-base options (K0108) height adjustable armrest -armrest options (K0108) moldable forearm 
support- right - armrest options (K0108) contoured hand pad large- right - armrest options (K0108) moldable 
forearm support- left - armrest options (K0108) push handles, corpus - accessories (K0108)  omni control 
module r-net w/ infrared-alt drive system setup (K0108) 3.5mm ext., cable for sensor/switch,1m long- alt drive 
accessories (K0108) IZIP drive control for OMNI2 (K0108) wireless vertical tilt sensor w/ charger (K0108) 9 
pin interface cable for OMNI2 (K0108) side mount headband for tilt sensor (K0108) Flexsure feet w/hook-n-
loop closure , x-large , pair-foot support (K0108) Flexsure feet padded inserts, x-large, pair-foot support 
(K0108) contoured hand pad large - left - armrest options (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee has been wheelchair 
bound but has gained weight and is appealing a request for a new power wheelchair that can provide better 
support. The Plan denied your request. The Plan says the requested wheelchair accessories are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The seat elevator and the push handles do not serve a primary 
medical purpose and is statutorily non-covered. All armrest options are already included with the approved 
E1007 power tilt and recline. The K0108 items are part of the expandable controller and should not be 
requested separately. All items needed for expandable controller to work properly are already included with the 
requested E2377 expandable controller. All head controllers, when properly coded, have all necessary 
electronics and switches needed to operate properly. These must not be unbundled. K0108 for any part of the 
head control cannot be approved. K0108 ankle straps cannot be covered, as they are miscoded. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve  power seat elevation system (E2300) 
enhanced steering perform unit-base options (K0108) height adjustable armrest -armrest options (K0108) 
moldable forearm support- right - armrest options (K0108) contoured hand pad large- right - armrest options 
(K0108) moldable forearm support- left - armrest options (K0108) push handles, corpus - accessories (K0108)  omni control module r-net w/ infrared-alt drive system setup (K0108) 3.5mm ext., cable for sensor/switch,1m 
long- alt drive accessories (K0108) IZIP drive control for OMNI2 (K0108) wireless vertical tilt sensor w/ 
charger (K0108) 9 pin interface cable for OMNI2 (K0108) side mount headband for tilt sensor (K0108) 
Flexsure feet w/hook-n-loop closure , x-large , pair-foot support (K0108) Flexsure feet padded inserts, x-large, 
pair-foot support (K0108) contoured hand pad large - left - armrest options (K0108).