Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retractable joystick mount (E1028), expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311), toggle switches (K0108), a skin protection seat cushion (E2622), a positioning back cushion (E2620), a headrest (E0955), power seating system, tilt and recline (E1007), power elevating legrest (E1012) and a power seat elevation feature (E2300) for the enrollee.

You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that the records don't show these items are necessary for the enrollee.

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 these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The requested power wheelchair accessories such as the toggle switches, sling support for head and joystick mount are not considered medical in nature and are therefore not medically necessary as these items are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 

The skin protection seat cushion (E2622) and a positioning back cushion (E2620) are not medically necessary as there is no evidence of significant postural asymmetries, absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift on an objective evaluation on the physician medical progress notes. The letter of medical necessity indicate the patient is independent in pressure relief.

The documentation does not reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or significant edema of the lower extremities that requires an elevating legrest. The physician progress notes do not support that the patient is not at high risk for development of a pressure ulcer, does not use intermittent catheterization for bladder management and does not need a power seating system to manage increased tone or spasticity. The documentation does not support that the criteria for the power tilt/power recline and power elevating leg rest upgrades have been met.

The expandable controller, electronic connection and expandable controller harness are not medically necessary as this exceeds the patient's medical needs. The documentation does not reveal that the patient requires other types of proportional input devices or non-proportional input devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items.

We looked at this physician's review, the file, and Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-approve a retractable joystick mount (E1028), expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311), toggle switches (K0108), a skin protection seat cushion (E2622), a positioning back cushion (E2620), a headrest (E0955), power seating system, tilt and recline (E1007), power elevating legrest (E1012) and a power seat elevation feature (E2300) for the enrollee.