Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the ankle huggers. We decided that the Plan does not have to pre-
approve elbow support, cutout of tray, back adapter hardware, and expandable controller.  
 
You asked the Plan to pre-approve the ankle huggers, elbow support, cutout of tray, back adapter hardware, and 
expandable controller. You say that the enrollee has poor mobility. You say that the enrollee cannot move 
around their home without a power wheelchair. You also say that the enrollee's current PWC is beyond five 
years old and does not function properly. The Plan says that accessories requested with K0108 but have an 
assigned procedure code are not covered. The Plan says that the elbow supports, and hardware are included 
with already approved coded. The Plan also says that the tray cut does not serve a medical purpose. 
 
We decided that the Plan has to pre-approve the ankle huggers.  
 
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 to pre-approve the ankle huggers. Our reviewer says 
that the requested ankle huggers are medically reasonable and necessary in this case. Our reviewer found that 
the documentation indicates the enrollee has lower extremity weakness such that the foot straps would meet 
coverage criteria if correctly coded. Therefore, the reviewer found that the requested ankle huggers are 
medically reasonable and 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 the ankle huggers have been met Therefore, we decided that the Plan has to pre-
approve the ankle huggers.  
 
We also decided that the Plan does not have to pre-approve elbow support, cutout of tray, back adapter 
hardware, and expandable controller. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. The rules 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 the elbow support, cutout of tray, back 
adapter hardware, and expandable controller. Our reviewer says that the requested elbow support, cutout of 
tray, back adapter hardware, and expandable controller are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee has adequate upper body strength to manage standard 
power drives. The reviewer found that the requested elbow rests and hardware are included with the approved 
wheelchair. The reviewer found that the tray cut out does not serve a medical purpose and therefore is not 
covered. Therefore, the reviewer found that the requested elbow support, cutout of tray, back adapter hardware, 
and expandable controller are not medically reasonable and 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 the elbow support, cutout of tray, back adapter hardware, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve elbow support, 
cutout of tray, back adapter hardware, and expandable controller. 
 
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.