Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the expandable controller (E2377), the harness (E2313), an 
electronic connection (E2311), the power elevating leg rest/platform (E1012) and the wheelchair cushion 
(K0699). We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and 
the mudguard kit (K0108).  
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration. The Plan says that the seat lift does not serve a primary medical purpose. This cannot 
be covered. Upgraded electronics (electronic connection, expandable controller, and harness) cannot be 
covered per Medicare rules. They are necessary when there is a medical need to control multiple power options 
though the joystick. Only one power option is approved. The mud guards do not serve a medical purpose and 
cannot be covered. Medicare rules say that non-approved wheelchair cushions cannot be covered. 
 
We decided that the Plan has to pre-approve the expandable controller (E2377), the harness (E2313), an 
electronic connection (E2311), the power elevating leg rest/platform (E1012) and the wheelchair cushion 
(K0699).  
 
The Plan follows 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 for an expandable controller, a harness, an electronic 
connection, the power elevating leg rest/platform, and the wheelchair cushion. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a medical history of congenital quadriplegia, cervical spinal stenosis, and 
spinal fusion. She requires a non-invasive ventilator and BiPAP. A functional mobility evaluation dated April 
11, 2022, indicated that the enrollee is non-ambulatory and requires assistance with all her daily activities. Her 
current power wheelchair is over 12 years in age and requires replacement and does not fit her properly due to 
changes in her size. She is noted to have 1-2/5 motor strength in the upper extremities. She is also noted to have 
lower extremity edema and contracture. The enrollee is non-ambulatory and requires a power wheelchair for 
mobility and performing her basic daily activities. She cannot perform pressure relief independently due to 
upper extremity weakness and requires a power wheelchair with power tilt for adequate pressure relief and 
positioning. She also requires power elevating leg rests for positioning of her lower extremities given her 
positioning needs and lower extremity contracture and edema. The complexity of her 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. The enrollee only has 2/5 motor strength in the left 
hand and requires that the power options be operated through the power joystick given her limited hand 
strength and dexterity due to her condition. The enrollee also requires a back and seat cushion for appropriate 
pressure relief and positioning. Therefore, we decided that the Plan has to pre-approve the expandable 
controller (E2377), the harness (E2313), an electronic connection (E2311), the power elevating leg 
rest/platform (E1012) and the wheelchair cushion (K0699).  
 
We also decided that the Plan does not have to pre-approve the power seat elevation system (E2300) and 
the mudguard kit (K0108). 
 
The Plan follows 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 for a power seat elevation system and a mudguard kit. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the power seat elevation feature is not medically appropriate since the 
enrollee is dependent with transfers and the mudguard kit is not medical in nature. Therefore, we decided that 
the Plan does not have to pre-approve the power seat elevation system (E2300) and the mudguard kit (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.