Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313), expandable controller (E2377), adapter Plate Pelvic/Thigh Guide Pads (K0108 x2), stealth height adjustable receivers for arm rests (K0108 x2), Quantum Backup Camera Track Mount Bracket (K0108), Backup Camera Q- Logic Joystick Mount Bracket (K0108), and Quantum Back Up Camera (K0108).

You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable controller, adapter Plate Pelvic/Thigh Guide Pads, stealth height adjustable receivers for arm rests, Quantum Backup Camera Track Mount Bracket, Backup Camera Q- Logic Joystick Mount Bracket, and Quantum Back Up Camera. You say that [Enter appellant's argument from appeal letter, e.g., "...you need SNF care."] The Plan denied your request. The Plan says 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. A separate request for Adjustable Height Arm Rests and adapter Plate Pelvic/ Thigh Guide Pads should be denied as unbundled. The Plan also says the Quantum Backup Camera Track Mount Bracket, Backup Camera Q- Logic Joystick Mount Bracket, and Quantum Back Up Camera do not serve a primary medical purpose and cannot covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 harness, expandable controller, adapter Plate Pelvic/Thigh Guide Pads, stealth height adjustable receivers for arm rests, Quantum Backup Camera Track Mount Bracket, Backup Camera Q- Logic Joystick Mount Bracket, and Quantum Back Up Camera. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an expandable controller, and associated electronics are not medically necessary as the enrollee has adequate strength to manage standard power drives. Adapter Plate Pelvic/Thigh Guide Pads, stealth height adjustable receivers for arm rests, Quantum Backup Camera Track Mount Bracket, Backup Camera Q- Logic Joystick Mount Bracket, and Quantum Back Up Camera are not medically necessary and are unnecessary to meet the enrollee's needs. Our reviewer also found that the stealth height adjustable receivers for arm rests are miscoded. 

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 harness, expandable controller, adapter Plate Pelvic/Thigh Guide Pads, stealth height adjustable receivers for arm rests, Quantum Backup Camera Track Mount Bracket, Backup Camera Q- Logic Joystick Mount Bracket, and Quantum Back Up Camera have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313), expandable controller (E2377), adapter Plate Pelvic/Thigh Guide Pads (K0108 x2), stealth height adjustable receivers for arm rests (K0108 x2), Quantum Backup Camera Track Mount Bracket (K0108), Backup Camera Q- Logic Joystick Mount Bracket (K0108), and Quantum Back Up Camera (K0108).