Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery charger, single mode, for use with only one 
battery type (E2366), electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), expandable controller (E2377), special wheelchair seat height from floor (E1296), 
harness (E2313), hand or chin control interface, mini-proportional remote joystick (E2312), nonstandard seat 
frame width (E2340), nonstandard seat frame depth, 20 or 21 inches (E2342), foam filled drive wheel tire, any 
size, replacement only (E2386 x2), positioning belt/safety belt/pelvic strap (E0978), and shoulder elbow, 
mobile arm support attached to wheelchair, balanced, adjustable rancho (E2627). 
 
You asked the Plan to pre-approve a battery charger, electronic connection, expandable controller, special 
wheelchair seat height from floor, harness, hand or chin control interface, mini-proportional remote joystick, 
nonstandard seat frame width, nonstandard seat frame depth, 20 or 21 inches, positioning belt/safety belt/pelvic 
strap, and shoulder elbow, mobile arm support attached to wheelchair. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a battery charger, electronic connection, 
expandable controller, special wheelchair seat height from floor, harness, hand or chin control interface, mini-
proportional remote joystick, nonstandard seat frame width, nonstandard seat frame depth, 20 or 21 inches, 
positioning belt/safety belt/pelvic strap, and shoulder elbow, mobile arm support attached to wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. There is not a medical need for the upgraded electronics. The 
additional accessories are included in the authorized wheelchair. The requested accessories would be 
considered a duplicate service and are therefore not 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 a battery charger, electronic connection, expandable controller, special 
wheelchair seat height from floor, harness, hand or chin control interface, mini-proportional remote joystick, 
nonstandard seat frame width, nonstandard seat frame depth, 20 or 21 inches, positioning belt/safety belt/pelvic 
strap, and shoulder elbow, mobile arm support attached to wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a battery charger, single mode, for use with only one battery 
type (E2366), electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), expandable controller (E2377), special wheelchair seat height from floor (E1296), harness 
(E2313), hand or chin control interface, mini-proportional remote joystick (E2312), nonstandard seat frame 
width (E2340), nonstandard seat frame depth, 20 or 21 inches (E2342), foam filled drive wheel tire, any size, 
replacement only (E2386 x2), positioning belt/safety belt/pelvic strap (E0978), and shoulder elbow, mobile arm 
support attached to wheelchair, balanced, adjustable rancho (E2627).