Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), 
expandable controller (E2377), wheelchair component or accessory (lateral positioning wedge) (K0108), and 
wheelchair component or accessory (width extension for footplates) (K0108). 
 You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, harness for upgrade to expandable controller, expandable controller, lateral 
positioning wedge, and width extension for footplates. You say that the enrollee requires the use of a group 3 
power wheelchair. The Plan denied your request. The Plan says these items or services still do not meet the 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that wheelchair seat and back cushion codes are all-inclusive. 
Medicare rules also say that footplates do have specific codes which are K0040, K0041, or K0042. 
 
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 electronic connection between 
wheelchair controller and two or more power seating system motors, harness for upgrade to expandable 
controller, expandable controller, lateral positioning wedge, and width extension for footplates. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested items exceed the enrollee's medical needs and does not meet Medicare 
medical necessity criteria. The enrollee does not require a ventilator, or non-proportional input devices (e.g., 
sip and puff, head array, etc.). Our reviewer found that 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 power options on the wheelchair but 
the enrollee does not need to control the power options through a joystick. Our physician reviewer also found 
that the enrollee's upper extremity strength supports that they 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 electronic connection between wheelchair controller and two or more power 
seating system motors, harness for upgrade to expandable controller, expandable controller, lateral positioning 
wedge, and width extension for footplates have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), harness for upgrade to expandable controller (E2313), expandable controller (E2377), 
wheelchair component or accessory (lateral positioning wedge) (K0108), and wheelchair component or 
accessory (width extension for footplates) (K0108).