Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108), back modifications for 
shoulder guides (K0108), adjustable angle footplates (K0040), foam caster tires (E2219), and extension handles 
(E0961). 
 
You asked the Plan to pre-approve a transit system, back modifications for shoulder guides, adjustable angle 
footplates, foam caster tires, and extension handles. You say that the recommended items are critical to the 
enrollee's safe positioning, transport, respiration, swallowing, and relaxation of muscle tone in addition to their 
comfort and skin integrity. The Plan denied your request. The Plan says the transit system was denied because 
it is not needed for in-home use. The back modifications for shoulder guides were denied because they are 
included in the allowance for an approved item and are not available for separate payment. The Plan says the 
adjustable angle footplates are a duplication of a service because heavy-duty footplates were approved in the 
request. The foam caster tires were denied because poly casters are included with the approved items and meet 
the enrollee's needs. The Plan also says that the manual wheel lock extension handles were denied as a 
convenience item for the enrollee's caregivers because the enrollee is dependent on caregivers for propulsion 
and transfers. 
 
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 a transit system, back modifications for 
shoulder guides, adjustable angle footplates, foam caster tires, and extension handles. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a transit system (K0108) is not medically necessary as this is not needed for use in the home. 
Adjustable angle footplates (K0040), foam caster tires (E2219), and back modifications for shoulder guides 
(K0108) are not medically necessary. Our reviewer found that the K0040 and E2219 items exceed the 
enrollee's medical need, as heavy-duty footplates and polycasters were approved by the health plan and 
Medicare states that equipment is necessary if the equipment does not serve the same purpose as other 
equipment already made available. Our physician reviewer also found that the enrollee is dependent on 
caregivers for propulsion and transfers therefore the E0961 manual wheel lock extension handles are not 
medically necessary and are a convenience item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transit system, back modifications for shoulder guides, adjustable angle 
footplates, foam caster tires, and extension handles have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transit system (K0108), back modifications for shoulder guides (K0108), adjustable 
angle footplates (K0040), foam caster tires (E2219), and extension handles (E0961).