Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve electronic connection (E2311), harness for upgrade to 
expandable controller (E2313), and expandable controller (E2377). We decided that the Plan does not have 
to pre-approve power seat elevation feature (E2300) and Ottobock extremity support hand pad (K0108).  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, E2300, 
K0108). You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve electronic connection (E2311), harness for upgrade to 
expandable controller (E2313), and expandable controller (E2377).  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are 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 additional power wheelchair 
accessories. Our reviewer says that the expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311) is medically necessary. Our physician reviewer found the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing his basic daily activities. The enrollee cannot perform 
pressure relief independently due to weakness and has pressure wounds. He requires a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. He also requires power elevating leg rests 
for positioning of his lower extremities. The complexity of his 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, including, 
tilt, recline and elevating leg rests, via a joystick.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional power wheelchair accessories have been met. Therefore, we decided 
that the Plan has to pre-approve electronic connection (E2311), harness for upgrade to expandable controller 
(E2313), and expandable controller (E2377).  
 
We also decided that the Plan does not have to pre-approve power seat elevation feature (E2300) and 
Ottobock extremity support hand pad (K0108). 
 
The Plan follows Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
Medicare rules say that a power seat elevation feature (E2300) is not covered because it is not primarily 
medical in nature. The Ottobock extremity support hand pad does not serve a purpose that is primarily medical 
in nature.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature (E2300) and Ottobock extremity support hand pad (K0108). have not 
been met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation feature 
(E2300) and Ottobock extremity support hand pad (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.