Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the custom seat cushion (K0108). We decided that the Plan does 
not have to pre-approve a power seating system (E2300), power standing system (E2301), back rest frame 
(K0108), arm gel pads (K0108 x2), chest support (K0108), adjustable height panel bracket left (K0108), and 
custom vs knee support covers (K0108).  
 
  You asked the Plan to pre-approve a power seating system (E2300), power standing system (E2301), custom 
seat cushion (K0108), back rest frame (K0108), arm gel pads (K0108 x2), chest support (K0108), adjustable 
height panel bracket left (K0108), and custom vs knee support covers (K0108). You say that the enrollee 
requires a new power wheelchair with power tilt/recline, standing, elevating leg rests, and seat elevation for 
functional performance of mobility related activities of daily living (MRADLs), functional mobility, and to 
gain the medical benefits of standing. You also say that the enrollee is unable to transfer independently with 
their arms or legs, and is dependent on ceiling lift for transfers in the home. The Plan says that the power seat 
elevator code is unable to be approved because the records received did not show that the enrollee can use the 
seat elevation feature in the home, and that the enrollee is able to transfer using their arms or legs. The power 
standing feature is not medical in nature, and is not covered. The Plan also says that code K0108 is unable to be 
approved for the custom seat cushion and back rest, arm gel pads, chest support, adjustable height panel 
bracket left, and custom vs knee support covers as they were submitted with improper codes. 
 
We decided that the Plan has to pre-approve the custom seat cushion (K0108).  
 
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 the custom seat cushion and back rest 
frame (K0108). Our reviewer says that the custom seat cushion is medically necessary for the enrollee. Our 
physician reviewer found the patient requires a custom seat cushion given their neuroscoliosis  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the custom seat cushion and back rest frame (K0108) have been met. Therefore, 
we decided that the Plan has to pre-approve the custom seat cushion (K0108).  
 
We also decided that the Plan does not have to pre-approve a power seating system (E2300), power 
standing system (E2301), back rest frame (K0108), arm gel pads (K0108 x2), chest support (K0108), 
adjustable height panel bracket left (K0108), and custom vs knee support covers (K0108). 
 
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 power seating system (E2300), power 
standing system (E2301), back rest frame (K0108), arm gel pads (K0108 x2), chest support (K0108), adjustable 
height panel bracket left (K0108), and custom vs knee support covers (K0108). Our reviewer says that these 
items and accessories are not medically necessary. Our physician reviewer found the complexity of the 
enrollee's seating and positioning needs necessitates a more complex group 3 power wheelchair base. However, 
the enrollee is dependent with transfers and requires a Hoyer lift. Our reviewer found that a power seat elevator 
will not significantly increase the enrollee's level of independence. Additionally, a power standing system is not 
medically necessary and not supported by the medical literature. If the patient requires standing, then a 
standard standing frame can be utilized. Our physician reviewer also found that the remaining accessories have 
a lack of documentation indicating why they 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 power seating system (E2300), power standing system (E2301), back rest frame 
(K0108), arm gel pads (K0108 x2), chest support (K0108), adjustable height panel bracket left (K0108), and 
custom vs knee support covers (K0108) have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seating system (E2300), power standing system (E2301), back rest frame (K0108), arm 
gel pads (K0108 x2), chest support (K0108), adjustable height panel bracket left (K0108), and custom vs knee 
support covers (K0108). 
 
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.