Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller, harness for upgrade to expandable controller, 2.0 degrees Active Reach, electronic connection between wheelchair controller and 2 or more power seating system motors, stealth gel pads, and elbow support left and right.  You asked the Plan to pre-approve a power seat elevation system, expandable controller, harness for upgrade to expandable controller, 2.0 degrees Active Reach, electronic connection between wheelchair controller and 2 or more power seating system motors, stealth gel pads, and elbow support left and right. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that 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, expandable controller, harness for upgrade to expandable controller, 2.0 degrees Active Reach, electronic connection between wheelchair controller and 2 or more power seating system motors, stealth gel pads, and elbow support left and right. Our reviewer says that the items are not medically necessary. Our physician reviewer found a seat elevator does not serve a primary medical purpose. As the E2300 seat elevator is not medically necessary the K0108 functional reach package is not medically necessary as this is for use with an adjustable power seat height. The K0108 gel pads are not primarily medical nature as there is no evidence in the documentation indicating the enrollee is unable to use standard pads. This request exceeds the enrollee's medical needs and is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) as Medicare does not pay for any items or services that 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 enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the patient can control any power options through their own switches.  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, expandable controller, harness for upgrade to expandable controller, 2.0 degrees Active Reach, electronic connection between wheelchair controller and 2 or more power seating system motors, stealth gel pads, and elbow support left and right have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller, harness for upgrade to expandable controller, 2.0 degrees Active Reach, electronic connection between wheelchair controller and 2 or more power seating system motors, stealth gel pads, and elbow support left and right.