Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), small calf panel (K0108), bracket assembly, footplate outside edge, with mounting 
hardware (K0108), center mount footplate connector bracket (K0108), footplate width extension with mounting 
hardware (K0108), large palm extensor (K0108), left, flip-back armrest down post (K0108), and right, flip-
back armrest down post (K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee is a 
candidate for the requested group 3 power wheelchair to improve their ability to mobilize throughout their 
home environment, reduce risk of future skin breakdown, improve their independence and safety with activities 
of daily living/instrumental activities of daily living, reduce chronic pain, and improve their overall quality of 
life. The Plan denied your request. The Plan says that the upgraded electronics (expandable controller, harness 
and electronic connector) are not medically necessary and cannot be covered. The calf pads are unbundled, and 
replacement pads cannot be approved with initial issue. The Plan says the codes used for the foot plates do not 
match the items requested and cannot be approved as requested. The code used for the power leg lifts do not 
match the item requested and cannot be covered. The Plan says the footplate extension is miscoded. Hand pads 
do not serve a medical purpose and cannot be covered. The Plan also says that armrests are already included 
with the approved wheelchair and requested arm rests cannot be approved. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing daily activities. They cannot perform pressure relief independently due to upper extremity 
weakness and require a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. There is a history of skin breakdown. Power elevating leg rests are required for positioning of the 
lower extremities. The complexity of the enrollees 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 via a joystick. These 
components are required to operate 3 or more power options on a group 3 power wheelchair. The wheelchair 
accessories, including calf panel, mounting hardware, center mount footplate, footplate extension, palm 
extension, and flip-back armrests, are also medically necessary to support the patients upper and lower limbs 
while in the power wheelchair. Therefore, the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) is medically necessary. The small calf panel (K0108), bracket assembly, 
footplate outside edge, with mounting hardware (K0108), center mount footplate connector bracket (K0108), 
footplate width extension with mounting hardware (K0108), large palm extensor (K0108), left, flip-back 
armrest down post (K0108), and right, flip-back armrest down post (K0108) is 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 the durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), small calf panel (K0108), bracket assembly, footplate outside edge, with mounting hardware (K0108), 
center mount footplate connector bracket (K0108), footplate width extension with mounting hardware (K0108), 
large palm extensor (K0108), left, flip-back armrest down post (K0108), and right, flip-back armrest down post 
(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.