Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a center mount power elevating leg rest/platform (E1012). We 
decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377).  
 
You asked the Plan to pre-approve a center mount power elevating leg rest/platform (E1012), electronic 
connection (E2311), expandable controller harness (E2313), and expandable controller (E2377). You say that 
you would like the documentation provided to be reconsidered for the K0856 base and all recommended 
components needed to meet the enrollee's current medical, mobility, and functional needs. The Plan says that 
the center mount power elevating leg rests and upgraded electronics are not medically necessary. 
 
We decided that the Plan has to pre-approve a center mount power elevating leg rest/platform (E1012).  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
 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 item/service at issue. Our reviewer 
says that a power elevating leg rest is medically necessary. Our physician reviewer found the provided records 
document the enrollee has a musculoskeletal condition of the left leg which prevents 90-degree flexion at the 
knee (they are reported to be in a left knee immobilizer) that would meet Medicare criteria for a power 
elevating leg rest. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve a center mount power elevating leg rest/platform (E1012).  
 
We also decided that the Plan does not have to pre-approve an electronic connection (E2311), 
expandable controller harness (E2313), and expandable controller (E2377). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 center mount power elevating leg 
rest/platform (E1012). Our reviewer says that an electronic connection, expandable controller harness, and 
expandable controller are not medically necessary. Our physician reviewer found that the records are 
contradictory with regard to the control device needed by the enrollee. The physician notes of August 31, 2023, 
reports need for a joystick for the right hand; a physical therapy note reports the need for a chin control. Our 
reviewer found the provided records document that the enrollee has 3 out of 5 right upper extremity grip 
strength with improved strength in right arm and hand and they can flex right arm to mouth. Our physician 
reviewer also found that the records do not clearly document the enrollee is unable to operate the wheelchairs 
power options with their own switches or clarify if a joystick or chin control is needed.  
 
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 center mount power elevating leg rest/platform (E1012) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable 
controller harness (E2313), and expandable controller (E2377). 
 
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.