Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311) and a manual swingaway, retractable or removable mounting 
hardware for joystick, other control interface or positioning accessory (E1028). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that you disagree with the denial. 
The Plan denied your request. The Plan says that there is not a medical need to control these power options 
through the joystick. The medical records document that the enrollee is setup-independent with feeding. Since 
the option joystick is not necessary, the swingaway interface for joystick is also not 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 power wheelchair accessories. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee cannot functionally ambulate using a cane or walker. He has a 
manual wheelchair but is unable to propel it for mobility and accomplishing daily activities. 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 requires a power wheelchair with power tilt 
for adequate pressure relief and positioning. He also requires power elevating leg rests for positioning. The 
electronic connection is necessary to operate the group 2 power wheelchair base and the power tilt and power 
articulating platform via a joystick, which is required to operate the power wheelchair. The swingaway 
mounting hardware is also necessary to allow the enrollee to transfer in and out of the wheelchair and moving 
the joystick controller to accomplish this. Therefore, the electronic connection (E2311) and manual swingaway 
mounting hardware (E1028) are 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 power wheelchair accessories have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311) and a manual swingaway, retractable or removable mounting hardware for joystick, 
other control interface or positioning accessory (E1028).  
 
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.