Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve attendant control, JS mount track hardware, a footplate, and 
footplate width extension bracket. We decided that the Plan does not have to pre-approve a power seat 
elevation system and backup Quantum camera.  
 
You asked the Plan to pre-approve a power seat elevation system, backup Quantum camera, attendant control, 
JS mount track hardware, a footplate, and footplate width extension bracket. You say that the items are 
medically necessary. The Plan says that based on the documentation provided, coverage criteria have not been 
met. 
 
We decided that the Plan has to pre-approve attendant control, JS mount track hardware, a footplate, 
and footplate width extension bracket.  
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 attendant control, JS mount track 
hardware, a footplate, and footplate width extension bracket. Our reviewer says that the items are medically 
necessary. Our physician reviewer found the clinical documentation indicates the items are necessary due to the 
degree of spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of attendant control, JS mount track hardware, a footplate, and footplate width 
extension bracket have been met. Therefore, we decided that the Plan has to pre-approve attendant control, JS 
mount track hardware, a footplate, and footplate width extension bracket.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system and backup 
Quantum camera. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 a power seat elevation system and 
backup Quantum camera. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the items are not listed for medical use and are requested out of convenience.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seat elevation system and backup Quantum camera have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and backup 
Quantum camera. 
 
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.