Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), expandable controller harness 
(E2313), and electro connect (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 electro connect (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 electro 
connect (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 that the requested expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (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 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 an expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (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 electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick are medically necessary. Our physician reviewer found the enrollee has 
a relevant past medical history of cerebrovascular accident (stroke) with weakness, diabetes mellitus 2 with 
neuropathy who is being evaluated for a Group 3 power wheelchair with expandable controller and harness, 
electro connect to control power tilt, recline and power elevating leg rests through a joystick to improve 
independence with mobility. Initially a group 3 power wheelchair was denied, upon subsequent review a group 
3 power wheelchair with power tilt, recline and power elevating leg rests was approved however the 
expandable controller and harness with electro connect to power functions through a joy stick was deemed 
medically unnecessary. 
 
Based on the documentation provided, the enrollee does have a covered indication for requested expandable 
controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick. Clinical documentation clearly states that enrollee 
has suffered a stroke with complications including reduced range of motion and reduced strength in both upper 
extremities and the rational for an expandable controller, expandable controller harness with electro connect to 
above power functions (power tilt, recline and elevating leg rests) is clearly stated. Enrollee requires these 
functions through the joy stick in order to perform activities of daily living and transfers at different heights, 
angles and setups within different rooms of the enrollees home environment thus the requested expandable 
controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick is medically reasonable and 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 an expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick have 
been met. Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick.  
 
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.