Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electrical connection between the wheelchair controller and two 
or more motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the current wheelchair is over five 
years old and has had $4605 in repairs completed. It currently requires approximately $5000 in repairs. Due to 
the age of the chair and the significant number of repairs, it is more cost effective to replace. The Plan denied 
your request. The Plan says that although there are two approved power options on this wheelchair, there is not 
a medical need to control these power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found a medical history of hypertension, type II diabetes mellitus, hyperlipidemia and 
strokes with aphasia and right sided hemiparesis. A power mobility evaluation dated December 27, 2022, 
indicated that the enrollee is non-ambulatory. She is unable to independently perform transfers or weight shifts 
and has a history of pressure wounds. Her current power wheelchair is greater than five years old and in 
disrepair. It requires replacement. The enrollee is non-ambulatory and requires a power wheelchair for mobility 
and performing her basic daily activities. She cannot perform pressure relief independently due to weakness 
and spasticity and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. The enrollee also requires power elevating leg rests for positioning and her lower extremity 
spasticity. The complexity of her seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the power tilt and recline and power elevating leg rests via a joystick. The 
patient is hemiplegic due to her stroke and requires the power options to be operated via a joystick. Therefore, 
the expandable controller (E2377) with harness (E2313) and electronic connection (E2311) is 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 wheelchair accessories have been met. Therefore, we decided that the Plan has 
to pre-approve an electrical connection between the wheelchair controller and two or more motors (E2311), a 
harness (E2313) and an expandable controller (E2377).  
 
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.