Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve expandable controller with harness and electronic connection. 
We decided that the Plan does not have to pre-approve power seat elevation, transit option, and gel foot plate.  
 
You asked the Plan to pre-approve an expandable controller (E2377), harness (E2313), electronic connection 
(E2311), power seat elevation (E2300), transit option (K0108), and gel foot plate (K0108). You say that the 
enrollee requires power tilt and power recline to meet his mobility and medical needs. You also say that the 
requested accessories are medically necessary. The Plan says that upgraded electronics are not medically necessary. The Plan also says gel pads, seat lift and transit option do not serve a medical purpose and cannot be 
covered. 
 
We decided that the Plan has to pre-approve expandable controller with harness and electronic 
connection.  
 
The Plan follows 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 expandable controller with harness and 
electronic connection. Our reviewer says that the expandable controller with harness and electronic connection 
are medically necessary. Our physician reviewer found the complexity of the enrollee's 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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve expandable controller with harness and electronic 
connection.  
 
We also decided that the Plan does not have to pre-approve power seat elevation, transit option, and gel 
foot plate. 
 
The Plan follows Medicare rules. Medicare rules say that payment will not be made for equipment that is 
primarily and customarily used for nonmedical purposes. 
  
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation, transit option, and gel foot plate have not been met. Specifically, these items 
are not medical in nature and therefore are not covered items. Therefore, we decided that the Plan does not 
have to pre-approve power seat elevation, transit option, and gel foot plate. 
 
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.