Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a harness (E2313) and expandable controller (E2377). We decided 
that the Plan does not have to pre-approve a backpack holder (K0108).  
 
You asked the Plan to pre-approve a harness (E2313), expandable controller (E2377), and a backpack holder 
(K0108). You say that you would like the necessary electronics to be approved for the power wheelchair. The 
Plan says that the harness and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). The Plan also says that a 
backpack holder does not serve a medical purpose and cannot be covered as they are not reasonable and 
necessary per Medicare criteria. 
 
We decided that the Plan has to pre-approve a 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 a harness (E2313) and expandable 
controller (E2377). 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 power wheelchair for mobility and performing their basic daily activities. The enrollee cannot 
perform pressure relief independently due to weakness and requires a power wheelchair with power tilt for 
adequate pressure relief and positioning. Our reviewer found that the enrollee also requires power elevating leg 
rests for positioning of their lower extremities and lower extremity spasticity and edema. 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 is necessary to operate the group 3 
power wheelchair base and the power options, including, tilt and elevating leg rests, 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 a harness (E2313) and expandable controller (E2377) have been met. Therefore, 
we decided that the Plan has to pre-approve a harness (E2313) and expandable controller (E2377).  
 
We also decided that the Plan does not have to pre-approve a backpack 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 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 a backpack 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.