Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick. 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the 
joystick. You say 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. The Plan denied your request. The Plan says 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 not medically necessary. 
 
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 (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. 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 not medically necessary. Our physician reviewer 
found the expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) 
and other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) are not medically necessary. 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 enrollee 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 an expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick.