Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated back cushion (E2617), expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve a custom fabricated back cushion (E2617), expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. You say that the requested custom fabricated back cushion 
(E2617), expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are medically 
necessary. The Plan denied your request. The Plan says that the requested custom fabricated back cushion 
(E2617), expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. 
 
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 a custom fabricated back cushion 
(E2617), expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that 
the requested custom fabricated back cushion (E2617), expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick are medically necessary. Our physician reviewer found the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing his basic daily activities. He cannot perform pressure 
relief independently due to weakness and an upper extremity amputation and requires a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. He also requires power elevating leg rests 
for positioning of his lower extremities and lower extremity contracture. The complexity of his 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, including, tilt, recline and elevating leg rests, via a joystick. Additionally given the enrollee's 
spinal symmetry and history of spine surgery, he requires a custom fabricated back cushion for appropriate 
support and prevent of skin breakdown. Therefore, the expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) and custom fabricated back cushion (E2617) 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 a custom fabricated back cushion (E2617), expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick have been met. Therefore, we decided that the Plan has to pre-
approve a custom fabricated back cushion (E2617), expandable controller (E2377), expandable controller 
harness (E2313), and electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick.  
 
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.