Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection, expandable controller, and harness. We 
decided that the Plan does not have to pre-approve push handles and Colorado prep and assembly.  
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors (E2311), push handles (K0108 x2), expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and Colorado prep and assembly (A9900 x6). You say that the 
services are necessary. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
We decided that the Plan has to pre-approve an electronic connection, expandable controller, and 
harness.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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, expandable 
controller, and harness. Our reviewer says that the services are medically necessary. Our physician reviewer 
found 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 electronic connection, expandable controller, and harness have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection, expandable controller, and 
harness.  
 
We also decided that the Plan does not have to pre-approve push handles and Colorado prep and 
assembly. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
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 push handles and Colorado prep and 
assembly. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
Colorado prep and assembly and push handles should be included in the assembly of the power wheelchair and 
are not 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 push handles and Colorado prep and assembly have not been met. Therefore, 
we decided that the Plan does not have to pre-approve push handles and Colorado prep and assembly. 
 
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.