Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), expandable controller harness 
(E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests through 
the joystick. 
 You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the 
joystick. You say that the requested expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick 
are medically necessary. The Plan denied your request. The Plan says that the requested expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are not medically necessary. 
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. Our reviewer says that the requested expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are medically necessary. Our physician reviewer 
found the enrollee is with past medical history of multiple sclerosis with functional impairments using a loaned 
group 3 PWC for mobility. Authorization for group 3 PWC with power tilt, recline and elevating leg rests with 
electronic connection to the joystick for control of power functions, plan approved all except for upgraded 
electronics through the joystick. Per clinical documentation, E2377, E2313, and electronic connection E2311 
are required as enrollee's functional condition is variable due to spasticity and other external variables 
throughout the day including upper limb function. In addition, there are 3 power functions thus electronic 
connection through the joystick is 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 an expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick 
have been met. Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick.  
 
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.