Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). We decided that the Plan does not have to pre-approve an attendant control 
(E2331).  
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), and attendant control (E2331). You 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. You also say that the denial of the attendant control does not make the base or any other accessories 
unusable. 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 
an attendant control cannot be covered in addition to a beneficiary-operated joystick. 
 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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. 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 their basic daily activities. The enrollee 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 enrollee requires power elevating leg rests for positioning of their 
lower extremities and lower extremity spasticity. Our reviewer found that the enrollee requires a power seat 
elevator to be independent with transfers. The complexity of the enrollee's 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. Our physician reviewer also found that these components are required to operate 3 or more 
power options on a group 3 power wheelchair. 
 
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 (E2311), harness (E2313), and expandable controller 
(E2377) have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), and expandable controller (E2377).  
 
We also decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
The Plan follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Specifically, a beneficiary-operated drive control is built into the base 
wheelchair that was approved. Based on this information, we decided that Medicare rules for coverage of an 
attendant control (E2331) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an attendant control (E2331). 
 
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.