Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and a bracket 
assay, footplate connector and footplate width extension (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the wheelchair and all accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the codes used for the 
foot plate assembly do not match the items requested. The notes do not show a medical need to control the 
power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a medical history of Parkinson's disease. Other conditions are notable 
for multiple sclerosis. A mobility evaluation dated August 2, 2023, indicated that the enrollee is functionally 
non-ambulatory and is requiring minimal assistance with transfers. The enrollee is requiring minimal assistance 
with daily activities, including toileting, dressing, and bathing/showering. Motor strength in the upper 
extremities is noted to be 2-3/5 and 2-3/5 in the lower extremities. Sensation is impaired. There is no history of 
skin breakdown. The enrollee is noted to have edema in the lower extremities. The enrollee is functionally non-
ambulatory and requires a power wheelchair for mobility and performing daily activities. They cannot perform 
pressure relief independently due to upper extremity weakness and require a power wheelchair with power tilt 
and recline for adequate pressure relief and positioning. Power elevating leg rests are required for positioning 
of the lower extremities and lower extremity edema. The complexity of the enrollee's 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 bracket assay, footplate connector and width extender are medically necessary to support the 
enrollee's lower extremities while in the power wheelchair. Therefore, the expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) and the bracket assay, footplate connector and width 
extender (K0108 x2) are 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 wheelchair accessories have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), a harness (E2313), an expandable controller (E2377) and a bracket assay, footplate connector 
and footplate width extension (K0108x2).  
 
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.