Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). We decided that the Plan does not have to pre-approve a cup holder (K0108) 
and phone holder (K0108).  
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), cup holder (K0108), and phone holder (K0108). You say that you would like the medical 
documentation to support the need of the custom medical equipment being requested for the enrollee to be 
reviewed. You also say that when three or more power seating functions/actuators/motors are provided, one 
unit of E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan says that although there are 
three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. The Plan also says that a cup holder and phone holder 
do not service a medical need and cannot be covered. 
 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) is medically necessary. Our physician reviewer found the enrollee is non-
ambulatory and requires a power wheelchair for mobility and performing their basic daily activities. The 
enrollee cannot perform pressure relief independently due to upper extremity weakness. Our reviewer found 
that the enrollee 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 their lower extremities. The 
complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. Our physician reviewer also found that 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. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
We also decided that the Plan does not have to pre-approve a cup holder (K0108) and phone holder 
(K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal 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 cup holder (K0108) and phone holder (K0108). 
 
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.