Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a custom fabricated wheelchair seat cushion (E2609) and custom 
fabricated wheelchair back cushion (E2617). We decided that the Plan does not have to pre-approve an 
electronic connection (E2311), expandable controller harness (E2313), and expandable controller (E2377).  
 
You asked the Plan to pre-approve an electronic connection (E2311), expandable controller harness (E2313), 
expandable controller (E2377), custom fabricated wheelchair seat cushion (E2609), and custom fabricated 
wheelchair back cushion (E2617). You say that you would like the documentation provided to be reconsidered 
for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. The Plan 
says that the request for power wheelchair accessories cannot be covered. 
 
  We decided that the Plan has to pre-approve a custom fabricated wheelchair seat cushion (E2609) and 
custom fabricated wheelchair back cushion (E2617).  
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated seat cushion (E2609) and 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 the item/service at issue. Our reviewer 
says that the requested items are medically reasonable and necessary. Our physician reviewer found the 
provided records from the treating practitioner in this case document scoliosis and pelvic obliquity with a 
heavy right lean and with the documentation from the evaluating physical therapist, the records support the 
need for the custom fabricated wheelchair seat cushion (E2609) and custom fabricated wheelchair back cushion 
(E2617).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve a custom fabricated wheelchair seat cushion (E2609) and custom fabricated wheelchair back 
cushion (E2617).  
 
We also decided that the Plan does not have to pre-approve an electronic connection (E2311), 
expandable controller harness (E2313), and expandable controller (E2377). 
 
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 an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided records 
document that the enrollee has 3 to 4 out of 5 right upper extremity strength with functional range of motion. 
Records are inconsistent with regard to the enrollee's needs with activities of daily living; records 
simultaneously state the enrollee is independent with feeding and grooming and that they are minimum assist 
with feeding and grooming. Our reviewer found that overall, the records do not clearly support that the enrollee 
has inadequate upper extremity strength and function to operate the wheelchairs power options with their own 
switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items at issue have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313), and 
expandable controller (E2377). 
 
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.