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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). A Group 3 PWC with Multiple Power Options (K0861-K0864) is covered if: A. The Group 3 criteria IV(A) and IV(B) are met; and B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met. If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met, it will be denied as not reasonable and necessary. E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are requested to control power tilt, recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three requested 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. Member's NP notes that member has intact strength and coordination. Member's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. If the member does not qualify for the wheelchair base, none of the requested accessories can be covered. You can find this information in the Local Coverage Determination (LCD) Power Mobility Devices (L33789).
Expandable Controller - An electronic system that is capable of accommodating one or more of the following additional functions: a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick. b. Non-proportional input devices (e.g., sip and puff, head array, etc.) c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) An expandable controller may also be able to operate one or more of the following: d. A separate display (i.e., for alternate control devices) e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) f. An attendant control A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.