Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve upgraded electronics. We decided that the Plan does not have to 
pre-approve seat lift feature.  
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and accessories, 
including an electronic connection, harness upgrade, expandable controller, and seat lift feature (E2300).. You 
say that the enrollee is looking to pursue other funding opportunities for these non-covered accessories but does 
need a formal decision from the plan in order to do so. The Plan says that there is not a medical need to control 
the multiple power options through the joystick. The Plan also says that the seat lift feature is not medical in 
nature and therefore not covered. 
 
We decided that the Plan has to pre-approve upgraded electronics.  
 
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 upgraded electronics. Our reviewer says 
that the upgraded electronics are medically necessary. Our physician reviewer found you are non-ambulatory 
and require a power wheelchair for mobility and performing basic daily activities. The reviewer found you 
cannot perform pressure relief independently due to weakness and spasticity and require a power wheelchair 
with power tilt and recline for adequate pressure relief and positioning. The reviewer found you also require 
power elevating leg rests for positioning of your lower extremities and lower extremity spasticity. The reviewer 
found that the complexity of your 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, including, tilt, recline and elevating leg rests, via 
a joystick. Therefore, the reviewer found that the upgraded electronics are 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 upgraded electronics and seat lift feature have been met. Therefore, we decided 
that the Plan has to pre-approve upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve seat lift feature. 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation feature is non-covered because it 
is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve seat lift 
feature. 
 
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.