Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). We decided that the Plan does not have to pre-approve the color display 
(K0108).  
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), and color display (K0108). You say that the main reason for replacing the enrollee's current chair is 
due to the decline in their health. You also say that this request is medically necessary. The Plan says that 
although there are three requested power options (tilt, recline and elevating leg rests), there is not a medical 
need to control these power options through the joystick. 
 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
The Plan must follow 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 an electronic connection (E2311), 
harness (E2313), and expandable controller (E2377). Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is non-
ambulatory and requires a power wheelchair for mobility and performing her basic daily activities. The 
enrollee cannot perform pressure relief independently due to upper extremity weakness and requires a power 
wheelchair with power tilt and recline for adequate pressure relief and positioning. Our reviewer found that the 
enrollee requires power elevating leg rests for positioning of their lower extremities. The complexity of the 
enrollee's 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. Our physician reviewer also found that these 
components are required to operate 3 or more power options on a group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection (E2311), harness (E2313), and expandable controller 
(E2377) have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), and expandable controller (E2377).  
 
We also decided that the Plan does not have to pre-approve the color display (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 color display (K0108). Our physician 
reviewer found the color display is not medically necessary to operate the power wheelchair and is not 
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 a color display (K0108) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the color display (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.