Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), small calf panel (K0108), battery charger (E2366), standard remote joystick 
(E2374), footplate extension (K0108), bracket assembly footplate (K0108), footplate cover (K0108), cup 
holder (K0108), and universal serial bus (USB) charge port (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, small calf panel, 
battery charger, standard remote joystick, footplate extension, bracket assembly footplate, footplate cover 
(K0108), cup holder (K0108), and USB charge port. You say that the physical therapist has clearly stated in 
their wheelchair and seating evaluation that the enrollee requires all the features that have been requested to be 
authorized, and has documented the need for these items in a way that meets all of Medicare's documentation 
requirements. The Plan denied your request. The Plan says the requested calf pads (K0108) are miscoded, are 
unbundled from the power wheelchair base, and cannot be requested separately. The requested battery charger 
(E2366) and standard remote joystick (E2374) unbundled, and are included in the payment for the K0861 base. 
The Plan says that although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. The 
footplate extension and bracket are miscoded. The Plan also says the footplate cover (K0108), cup holder 
(K0108), USB charge port (K0108) do not serve a medical need and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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, harness, 
expandable controller, small calf panel, battery charger, standard remote joystick, footplate extension, bracket 
assembly footplate, footplate cover (K0108), cup holder (K0108), and USB charge port. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has sufficient strength and function in their upper extremities to manage standard 
power drives. The footplate cover (K0108), cup holder (K0108), USB charge port (K0108) do not serve a 
medical need and are, therefore, not medically necessary. Our reviewer found that the requested calf pads 
(K0108) unbundled from the power wheelchair base. Our physician reviewer also found that the battery 
charger (E2366) and standard remote joystick (E2374) are included with the K0861 base. 
 
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, harness, expandable controller, small calf panel, 
battery charger, standard remote joystick, footplate extension, bracket assembly footplate, footplate cover 
(K0108), cup holder (K0108), and USB charge port have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), small calf panel (K0108), battery charger (E2366), standard remote joystick (E2374), footplate 
extension (K0108), bracket assembly footplate (K0108), footplate cover (K0108), cup holder (K0108), and 
universal serial bus (USB) charge port (K0108).