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), a harness (E2313), an expandable controller (E2377) and a new 
push handle assay (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that all accessories are medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says that the upgraded electronics are not 
medically necessary. The notes do not show a medical need to control the options through the joystick. Push 
handles serve no medical purpose. 
 
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 the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing daily activities. They cannot perform pressure relief independently due to upper extremity 
weakness and require a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. There is a history of skin breakdown. Power elevating leg rests are required for positioning of the 
lower extremities and lower extremity spasticity. The complexity of the enrollees 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 three power options 
via a joystick. These components are required to operate 3 or more power options on a group 3 power 
wheelchair. The push handle assays are medically necessary given that the power wheelchair can still require 
positioning by an enrollees caregiver. Therefore, the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) is medically necessary. The push handle assay (K0108 x2) 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 electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), a harness (E2313), an expandable controller (E2377) and a new push handle assay (K0108x2).  
 
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.