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), Q-Logic 3 controller (K0108), modular footplate extension 
components, width pair (K0108 x2), and footplate connector (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, Q-Logic 3 controller, modular footplate extension components, width pair, and footplate connector. 
You say that you are paralyzed and have a chronic hip breaking issue. The Plan denied your request. The Plan 
says 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 Plan says the Q-Logic 3 
controller is already included with the requested expandable controller (E2377), and should not be requested 
separately. The Plan also says the modular footplate extension components and footplate connector are 
miscoded and cannot be covered as these exceed the member's need and are not reasonable and necessary per 
Medicare criteria. 
 
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, Q-Logic 3 controller, modular footplate extension components, width 
pair, and footplate connector. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not 
medically necessary as you do have use of the upper extremity and can operate and control the power options 
using the switches that are included in the basic wheelchair. There is not a medical need for the upgraded 
electronics or the specialized footplate and connector. Our reviewer found that the provided records document 
that you have 5 out of 5 bilateral upper extremity strength and are modified independent with dressing, 
grooming, bathing, and toileting thus indicating you have adequate upper extremity strength and function to 
operate the wheelchair's power options with your own switches. Our physician reviewer also found that the Q-
Logic 3 controller (K0108) is already included in the expandable controller (E2377) that has been reviewed and 
found to not meet Medicare criteria for coverage, thus the Q-Logic 3 controller (K0108) does not meet 
Medicare criteria for coverage.  
 
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, 
Q-Logic 3 controller, modular footplate extension components, width pair, and footplate connector 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), Q-Logic 3 controller (K0108), modular 
footplate extension components, width pair (K0108 x2), and footplate connector (K0108).