Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), direct backrest adapter hardware (K0108), universal headrest adapter hardware 
(K0108), push handles (K0108), custom fabricated wheelchair seat cushion (E2609), and custom fabricated 
wheelchair back cushion (E2617). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, direct backrest 
adapter hardware, universal headrest adapter hardware, push handles, custom fabricated wheelchair seat 
cushion, and custom fabricated wheelchair back cushion. You say that the wheelchair that you have is old, the 
seat is too small, and the footrest is broken. You also say that you have cerebral palsy and need your 
wheelchair to get around and function on a daily basis. The Plan denied your request. The Plan says these 
additional items are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that a custom fabricated seat cushion (E2609) and a custom 
fabricated back cushion (E2617) are covered if the criteria listed in the Medicare rules section of this letter are 
met. 
 
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, direct backrest adapter hardware, universal headrest adapter hardware, custom fabricated 
wheelchair seat cushion, and custom fabricated wheelchair back cushion. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is able to independently feed himself and transfer from bed to wheelchair and from 
wheelchair to commode, and is able to independently manage current power wheelchair. The enrollee has 
adequate upper body strength to manage standard power drives. Our reviewer found that the enrollee is clearly 
able to weight shift, has intact skin, and does not require custom fabricated wheelchair seat cushion (E2609) 
and a custom fabricated wheelchair back cushion for positioning. Our physician reviewer also found that the 
back rest and headrest hardware are unbundled as the hardware is covered with the approved back rest and 
headrest.  
 
Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose.   
 
We looked at this physician's review, the file, and Medicare rules. The requested push handles do not serve a 
purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for 
coverage of an electronic connection, harness, expandable controller, direct backrest adapter hardware, 
universal headrest adapter hardware, push handles, custom fabricated wheelchair seat cushion, and custom 
fabricated wheelchair back cushion have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electronic connection (E2311), harness (E2313), expandable controller (E2377), direct backrest 
adapter hardware (K0108), universal headrest adapter hardware (K0108), push handles (K0108), custom 
fabricated wheelchair seat cushion (E2609), and custom fabricated wheelchair back cushion (E2617).