Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), 
headrest hardware, a phone holder and a gel pad foot plate (K0108x3). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has multiple pressure 
ulcers and needs the wheelchair and accessories to move around. It's urgent that the enrollee gets his 
wheelchair. The Plan denied your request. The Plan says the upgraded electronics (expandable controller, 
harness and electronic connector to 2 power options) are not medically necessary. The phone holder and gel 
pads serve no medical purpose. The headrest hardware is already approved. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a power mobility device is medically necessary if an enrollee 
has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related 
activities of daily living. The mobility limitation cannot be sufficiently and safely resolved by the use of a fitted 
cane or walker, or the enrollee does not have sufficient upper extremity function to self-propel an optimally 
configured manual wheelchair. The enrollee must also have the mental and physical capabilities to safely 
operate the power wheelchair and the home provides adequate access between rooms, maneuvering space, and 
surfaces for the operation of the power wheelchair (PWC).  A group 2 PWC can be covered if the medical 
necessity for a PWC is met and if the enrollee also requires a drive control interface, power tilt or a power recline seating system and if there has been a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a physical or occupational therapist. The requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. The phone holder and gel pads do not 
serve a medical purpose and are not a covered benefit. The headrest hardware is already approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377), headrest hardware, a 
phone holder and a gel pad foot plate (K0108x3).