Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve  the electrical connection between the wheelchair controller 
and two or more motors (E2311) expandable controller (E2377) and harness (E2313). We decided that the 
Plan does not have to pre-approve positioning belt/safety belt/pelvic strap, each E0978 .  
 
You asked the Plan to pre-approve electrical connection between the wheelchair controller and two or more 
motors (E2311) expandable controller (E2377) and harness (E2313) positioning belt/safety belt/pelvic strap, 
each (E0978).. You say that the requested K0861 with required options is medically necessary. The Plan says 
that the seat belt is already included in the wheelchair and cannot be requested separately. The upgraded 
electronics are not medically necessary. 
 
We decided that the Plan has to pre-approve  the electrical connection between the wheelchair controller 
and two or more motors (E2311) expandable controller (E2377) and harness (E2313).  
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case.  
 
Our physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing his basic daily activities. The enrollee cannot perform pressure relief independently due to upper 
extremity weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief 
and positioning. The enrollee requires power elevating leg rests for positioning of the lower extremities. 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. These components are required to operate 3 or more 
power options on a group 3 power wheelchair. Therefore, the expandable controller (E2377) with harness 
(E2313) and electronic connection (E2311) 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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve  the electrical connection between the wheelchair controller and two or more motors (E2311) 
expandable controller (E2377) and harness (E2313).  
 
We also decided that the Plan does not have to pre-approve positioning belt/safety belt/pelvic strap, each 
E0978 . 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code E0978 
is listed under Column II, with approved Power Wheelchair Base Group 3 code K0861 listed under Column I. 
Therefore, payment of seat belt and related supplies is included with the approved Power Wheelchair Base 
Group 3 K0861. A separate request for the seatbelt is denied as unbundled. Therefore, we decided that the Plan 
does not have to pre-approve positioning belt/safety belt/pelvic strap, each E0978 . 
 
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.