Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and transfer handle assembly (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and transfer handle 
assembly. You say that the denial of the transfer handle assembly is not an integral part of the base, thus a split 
decision should be possible. You also say that when three or more power seating functions/actuators/motors are 
provided, one unit of E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan denied your 
request. The Plan says that although there are three requested power options (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. The Plan also says that 
transfer handles do not serve a medical purpose and cannot be covered. 
 
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 electronic connection, harness, 
expandable controller, and transfer handle assembly. Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the patient is non-
ambulatory and requires a power wheelchair for mobility and performing their basic daily activities. They 
cannot perform pressure relief independently due to upper extremity weakness and requires a power wheelchair 
with power tilt and recline for adequate pressure relief and positioning. The patient currently has a gluteal 
pressure wound. Our reviewer found that the patient requires power elevating leg rests for positioning of their 
lower extremities and lower extremity spasticity. The complexity of the patient's seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. Our physician reviewer found that 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. Our reviewer found that the patient also has impaired ability to transfer to and 
from the power wheelchair and therefore the transfer handle assembly is medically appropriate to assist with 
transfers. 
 
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 electronic connection, harness, expandable controller, and transfer handle 
assembly have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and transfer handle assembly (K0108).  
 
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.