Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300).

You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300). You say that the requested expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300) are medically necessary. The Plan denied your request. The Plan says the requested expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300) are not medically necessary.

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 a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.

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 (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300). Our reviewer says that the requested expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, an a power seat elevation feature (E2300) are not medically necessary. Our physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick.

The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.

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 (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick have not been met. Furthermore, Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), an electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick, and a power seat elevation feature (E2300).