Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311). We decided that the Plan does not have to pre-approve the left and right 
armrest (E0973), a power seat elevation system (E2300), pull up foot straps and accessory bar for push down 
footplates (K0108).  
 
You asked the Plan to pre-approve a left and right armrest (E0973), a power seat elevation system (E2300), an 
expandable controller (E2377), an expandable controller harness (E2313), an electronic connection (E2311), 
pull up foot straps and accessory bar for push down footplates (K0108). You say that a left and right armrest 
(E0973), a power seat elevation system (E2300), an expandable controller (E2377), an expandable controller 
harness (E2313), an electronic connection (E2311), pull up foot straps and accessory bar for push down 
footplates (K0108) are medically necessary. The Plan says that a left and right armrest (E0973), a power seat 
elevation system (E2300), an expandable controller (E2377), an expandable controller harness (E2313), an electronic connection (E2311), pull up foot straps and accessory bar for push down footplates (K0108) are not 
medically necessary. 
 
We decided that the Plan has to pre-approve the expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311).  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
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 (E2377) with 
harness (E2313) and electronic connection (E2311). Our reviewer says that the expandable controller (E2377) 
with harness (E2313) and electronic connection (E2311) are medically necessary. Our physician reviewer 
found the enrollee is with a medical history of facioscapulohumeral muscular dystrophy.  A power mobility 
evaluation dated June 13, 2022, indicated that the enrollee is functionally non-ambulatory due to lower 
extremity weakness. She is currently using a loaned group 3 power wheelchair for mobility. She has had 
progressive weakness since 2003 affecting her upper and lower limbs. She is noted to have 2/5 grip strength 
bilaterally and increased tone in the upper and lower extremities. 
 
The enrollee is non-ambulatory and requires a power wheelchair for mobility and performing her basic daily 
activities. She cannot perform pressure relief independently due to upper extremity weakness and spasticity and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. She also 
requires power elevating leg rests for positioning and her lower extremity spasticity. The complexity of her 
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 and power elevating leg rests via a joystick. Therefore, the expandable controller 
(E2377) with harness (E2313) and electronic connection (E2311) are medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311) have been met. Therefore, we decided that the Plan has to pre-approve the expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311).  
 
We also decided that the Plan does not have to pre-approve the left and right armrest (E0973), a power 
seat elevation system (E2300), pull up foot straps and accessory bar for push down footplates (K0108). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
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 pull up foot straps and accessory bar 
for push down footplates (K0108). Our reviewer says that the pull up foot straps and accessory bar for push 
down footplates are primarily convenience in nature, especially since the power seat elevator is not medically 
necessary and not considered medical in nature. Therefore, the pull up foot straps and accessory bar for push 
down footplates are not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pull up foot straps and accessory bar for push down footplates (K0108) have 
not been met.  
 
Medicare rules also say a Column II code is included in the allowance for the corresponding Column I code 
when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I. In this case, code E0973 is listed under Column II, and code E1007 is listed under 
Column I. Therefore, payment of E0973 is included in the approved E1007 code and should not be requested 
separately. 
 
Lastly, Medicare rules say a power seat elevation system (E2300) is statutorily non-covered by Medicare. 
 
Therefore, we decided that the Plan does not have to pre-approve the left and right armrest (E0973), a power 
seat elevation system (E2300), pull up foot straps and accessory bar for push down footplates (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.