Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an electronic connection (E2311), harness
(E2313), expandable controller (E2377).

You asked the Plan to provide coverage for electronic connection, harness, and expandable controller. The Plan
denied your request. The Plan says the required criteria for the electronic connection, harness, and expandable
controller were not met. Maximus overturned the Plans denial. The Plan requested are open and stated that
Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller (E2377), harness (E2313), and electronic connection (E2311). The Maximus Physician Reviewer
determined that the enrollee is functionally non-ambulatory and requires a power wheelchair for mobility and
performing her basic daily activities. The enrollee cannot perform pressure relief independently due to upper
extremity weakness and requires a power wheelchair with power tilt for adequate pressure relief and
positioning. The reviewer found that the enrollee requires power elevating leg rests for positioning the lower
extremities and lower extremity edema. The enrollee requires a power seat elevator to be independent with
transfers to and from the power wheelchair. The complexity of the enrollee's seating and positioning needs
necessitates a more complex Group 3 power wheelchair base. Our physician reviewer also found that 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.

The Plan requested a reopen and argues that, although there are three requested power options (tilt, recline and
elevating leg rests), there is not a medical need to control these power options through the joystick. "Member's
upper limb strength and function are adequate for the member to be able to control the power options using
their own switches which are included in the allowance of these power options."

The medical records show the enrollee is a 73-year-old woman with a diagnosis of multiple sclerosis, which
has affected all of her extremities. The enrollee has severe difficulty walking, difficulty getting out of bed, and
completing daily activities. On February 17,2023 it is documented that the enrollee was utilizing a Rollator and
had frequent falls. The enrollee was able to do upper and lower body dressing with excess time, effort, and/or
pain. Bathing required minimal assist. The Plan is correct in this case. The available clinical documentation in
the case file does not support that the requested expandable controller, harness, and electronic connection were
medically reasonable and necessary for the enrollee in this case. The notes do not show the medical necessity
of controlling the power options through a joystick. 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 requested
upgraded electronics are not met. Therefore, we decided that the Plan does not have to provide coverage for an
electronic connection (E2311), harness (E2313), expandable controller (E2377).