Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the electronic connection, (E2311) expandable controller 
(E2377) expandable controller harness (E2313). We decided that the Plan does not have to pre-approve bag 
hooks (K0108).  
 
You asked the Plan to pre-approve the electronic connection, (E2311) expandable controller (E2377) 
expandable controller harness (E2313) bag hooks (K0108). You say that please review the following for appeal 
of authorization. The Plan says that it is not medically necessary to control the three approved power options 
through the joystick (drive interface). The requested bag hooks serve no medical purpose and cannot be 
approved. 
 
We decided that the Plan has to pre-approve the electronic connection, (E2311) expandable controller 
(E2377) expandable controller harness (E2313). We also decided that the Plan does not have to pre-
approve bag hooks (K0108). 
 
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. The rules say that for 
equipment to be covered, it must primarily serve a medical purpose.   
 
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 upgraded electronics. Our reviewer 
says that the upgraded electronics are medically necessary in this case. Our physician reviewer found the 
enrollee is functionally non-ambulatory and requires a power wheelchair for mobility and performing basic 
daily activities. The enrollee cannot perform pressure relief independently due to weakness and has a history of 
skin breakdown and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. The enrollee also requires power elevating leg rests for positioning of lower extremities and due to 
spasticity. The complexity of the enrollees 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, including, tilt, recline and elevating leg 
rests, via a joystick. Therefore, the expandable controller (E2377) with harness (E2313) and electronic 
connection (E2311) is 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 the upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the electronic connection, (E2311) expandable controller (E2377) expandable controller harness 
(E2313). The requested bag hooks do 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. Based on this 
information, we decided that Medicare rules for coverage of bag hooks (K0108) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bag hooks (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.