Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a footrest, side guards, and gel leg protector wraps. We decided 
that the Plan does not have to pre-approve a luggage carrier and custom offset profiled side guards.  
 
You asked the Plan to pre-approve a footrest (K0108), side guards (K0108), gel leg protector wraps (K0108 
x2), luggage carrier (K0108), and custom offset profiled side guards (K0108). You say that the enrollee cannot 
complete any physical activity, any of his daily living activity, needs to go around the house, member is 
ambulatory and needs a wheelchair. The Plan says that these items do not meet the coverage criteria. 
 
We decided that the Plan has to pre-approve a footrest, side guards, and gel leg protector wraps.  
 
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 a footrest, side guards, gel leg protector 
wraps. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee is functionally non-ambulatory and requires a manual 
wheelchair for mobility and performing their basic daily activities. Our reviewer also found that the enrollee 
requires a footrest to position and support their lower extremity while in the wheelchair as well as side guards 
and gel wraps to protect their legs while in the wheelchair to prevent injury.  
 
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 footrest, side guards, and gel leg protector wraps have been met. Therefore, 
we decided that the Plan has to pre-approve a footrest, side guards, and gel leg protector wraps.  
 
We also decided that the Plan does not have to pre-approve a luggage carrier and custom offset profiled 
side guards. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 luggage carrier and custom offset 
profiled side guards. Our physician reviewer found the custom nature of the side guards and luggage carrier are 
not medically necessary as they are not medical related. 
 
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 luggage carrier and custom offset profiled side guards have not been met. The 
items at issue do not serve a purpose that is primarily medical in nature. These items are 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 a luggage carrier and custom offset profiled side guards. 
 
 
 
 
 
 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.