Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics, toggle switches, tray hardware, and 
power mount bracket. We decided that the Plan does not have to pre-approve a cellphone holder, and 
premium pad cover.  
 
You asked the Plan to pre-approve the upgraded electronics, toggle switches on ICS switchbox - seat function 
control, tray hardware - adjustable, power mount bracket, cellphone holder, and premium pad cover. You say 
that this is medically necessary for the enrollee. The Plan says that the upgraded electronics are not medically 
necessary. The Plan says that the toggle switch is included with the requested controller. The Plan says a cell 
phone holder does not have a medical purpose. The Plan says the tray hardware is included with the tray. The 
Plan says the power mount hardware is miscoded. The Plan also says the approved seat cushions includes all 
parts needed for it to work correctly. 
 
We decided that the Plan has to pre-approve the upgraded electronics, toggle switches, tray hardware, 
and power mount bracket.  
 
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 the upgraded electronics, toggle 
switches, tray hardware, and power mount bracket. Our reviewer says that the requested upgraded electronics, 
toggle switches, tray hardware, and power mount bracket are medically necessary. Our physician reviewer 
found the enrollee is non-ambulatory and requires a power wheelchair for mobility and performing basic daily 
activities. The enrollee 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. The 
enrollee requires power elevating leg rests for positioning of his lower extremities and lower extremity 
lymphedema. The complexity of their 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. The toggle switch is necessary to 
operate the power wheelchair components and the power mount bracket and tray hardware are necessary to 
mount wheelchair components. Therefore, the reviewer found that the requested upgraded electronics, toggle 
switches, tray hardware, and power mount bracket are medically reasonable and 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, toggle switches, tray hardware, and power mount 
bracket have been met. Therefore, we decided that the Plan has to pre-approve the upgraded electronics, toggle 
switches, tray hardware, and power mount bracket.  
 
We also decided that the Plan does not have to pre-approve a cellphone holder, and premium pad cover. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The cellphone holder and premium pad cover do not serve a purpose that is primarily medical in nature. These 
items are 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 cellphone holder, and premium pad cover. 
 
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.