Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve electronic connection, harness, and expandable controller. We 
decided that the Plan does not have to pre-approve seat lift feature.  
 
You asked the Plan to pre-approve a seat lift feature (E2300), electronic connection (E2311), harness (E2313), 
and expandable controller (E2377). You say that the enrollee was approved for power tilt, power recline, and 
power elevated leg rests. You say that these features are not operable without procedure codes E2311, E2377, 
E2313. You also say that the enrollee does not have 24/7 caregivers and requires this wheelchair to maintain 
her mobility related activities of daily living (MRADLs). The Plan says that the notes do not show a medical need to control the power options through the joystick. The Plan also says a seat elevator does not serve a 
primary medical purpose and is statutorily non-covered. 
 
We decided that the Plan has to pre-approve electronic connection, harness, and expandable controller.  
 
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 the requested features. Our reviewer 
says that the requested electronic connection, harness, and expandable controller are medically necessary. Our 
physician reviewer found the provided documentation indicates the enrollee requires a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. The enrollee also requires power elevating 
leg rests for positioning of her lower extremities and lower extremity spasticity. The complexity of their 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. Therefore, the reviewer found that the requested expandable controller with 
harness and electronic connection are 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 the requested features have been met. Therefore, we decided that the Plan has to 
pre-approve electronic connection, harness, and expandable controller.  
 
We also decided that the Plan does not have to pre-approve seat lift feature. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature and power standing 
feature are non-covered because they are not primarily medical in nature. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve seat lift feature. 
 
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.