Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and one 
power seating system motor (E2310). We decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300).  
 
You asked the Plan to pre-approve a power seat elevation system (E2300) and electronic connection between 
wheelchair controller and one power seating system motor (E2310). You say that the wheelchair and 
accessories are medically necessary to meet the enrollee's current needs. The Plan says that the seat elevator 
does not serve a primary medical purpose and is statutorily non-covered. The Plan also says that although a 
single power feature is requested for this wheelchair, there is not a medical need to control this power option 
through the joystick. 
 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and 
one power seating system motor (E2310).  
 
The Plan follows 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 electronic connection between 
wheelchair controller and one power seating system motor (E2310). Our reviewer says that the electronic 
connection (E2310) is medically necessary. Our physician reviewer found the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing their basic daily activities. The enrollee cannot 
adequately perform pressure relief due to weakness and spasticity and requires a power wheelchair with power 
tilt. Our reviewer found that the complexity of the enrollees seating and positioning needs necessitates a more 
complex group 3 power wheelchair base. Our physician reviewer also found that the electronic connection is 
necessary to operate the group 3 power wheelchair base and the power tilt feature 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 an electronic connection between wheelchair controller and one power seating 
system motor (E2310) have been met. Therefore, we decided that the Plan has to pre-approve an electronic 
connection between wheelchair controller and one power seating system motor (E2310).  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (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.