Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), an access harness for an 
expandable controller (E2313), and an electronic connection (E2311).  
 
You asked the Plan to pre-approve an expandable controller, an access harness for an expandable controller, 
and an electronic connection. . You say that the items which remain in dispute are medically necessary. The 
Plan denied your request. The Plan says that the notes do not show a medical need to control the power options 
through the joystick. The Plan says that the power options can be controlled using their own switches.  
 
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 expandable controller, an access 
harness for an expandable controller, and an electronic connection. . Our reviewer says that the requested items 
are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 
medical history of multiple sclerosis. A mobility evaluation dated May 16, 2023, indicated that the enrollee is 
functionally non-ambulatory and has a history of falling. She has 3/5 motor strength in the upper and lower 
extremities and spasticity. She cannot adequately perform pressure relief. The enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing her basic daily activities. She 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. She requires power elevating leg rests for positioning of 
her lower extremities and lower extremity spasticity. The complexity of her 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. 
 
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 expandable controller, an access harness for an expandable controller, and an 
electronic connection.  have been met. Therefore, we decided that the Plan has to pre-approve an expandable 
controller (E2377), an access harness for an expandable controller (E2313), and an electronic connection 
(E2311).   
 
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.