Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller, harness, and electronic connection 
(E2311, E2313, and E2377). We decided that the Plan does not have to pre-approve a seat belt for a power 
wheelchair (E0978) and a power seat elevation feature (E2300).  
 
You asked the Plan to pre-approve a seat belt for a power wheelchair (E0978), a power seat elevation feature 
(E2300), and an expandable controller, harness, and electronic connection (E2311, E2313, and E2377).. You 
say that the requested seat belt for a power wheelchair (E0978), a power seat elevation feature (E2300), 
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 
says that the requested seat belt for a power wheelchair (E0978), a power seat elevation feature (E2300), 
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. 
 
We decided that the Plan has to pre-approve an expandable controller, harness, and electronic 
connection (E2311, E2313, and E2377).  
 
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 an expandable controller, harness, and 
electronic connection (E2311, E2313, and E2377). 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 a medical history of cerebral palsy with spastic quadriplegia, hypertension, and lower 
extremity edema. A power mobility evaluation dated November 7, 2022, indicated that the enrollee is non-
ambulatory and requires assistance for his daily activities. He requires moderate to maximum assistance for transfers. The enrollee has 2/5 motor strength in the upper and lower extremities with decreased range of 
motion and spasticity. 
 
The enrollee is non-ambulatory and requires a power wheelchair for mobility and performing his basic daily 
activities. He cannot perform pressure relief independently due to weakness and spasticity and requires a power 
wheelchair with power tilt and recline for adequate pressure relief and positioning. He also requires power 
elevating leg rests for positioning and his lower extremity spasticity. The complexity of his 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 given the enrollees impaired upper strength 
coordination and spasticity. Therefore, the expandable controller with harness and electronic connection 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, harness, and electronic connection (E2311, E2313, 
and E2377) have been met. Therefore, we decided that the Plan has to pre-approve an expandable controller, 
harness, and electronic connection (E2311, E2313, and E2377).  
 
We also decided that the Plan does not have to pre-approve a seat belt for a power wheelchair (E0978) 
and a power seat elevation feature (E2300). 
 
The Plan must follow Medicare rules. The rules say that each power wheelchair basic equipment package 
includes a lap belt or safety belt. Medicare also specifically excludes coverage of power seat elevation systems 
coded as E2300. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a seat belt for a power wheelchair (E0978) and a power seat elevation feature (E2300) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a seat belt for a power wheelchair 
(E0978) and a power seat elevation feature (E2300). 
 
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.