Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller, harness, and electronic connection. We 
decided that the Plan does not have to pre-approve power seat elevation feature.  
 
You asked the Plan to pre-approve an expandable controller (E2377), harness (E2313), electronic connection 
between wheelchair controller and two or more power seating system motors (E23110, and power seat 
elevation feature (E2300).. You say that the items are necessary. The Plan says that based on the 
documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve an expandable controller, harness, and electronic 
connection.  
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 expandable controller, harness, and 
electronic connection. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the enrollee is functionally non-ambulatory and requires a power wheelchair for mobility and performing 
her basic daily activities. The complexity of her 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 power options, including power tilt and power 
elevating leg rests, via a joystick. Therefore, the expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) 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 an expandable controller, harness, and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller, harness, and electronic 
connection.  
 
We also decided that the Plan does not have to pre-approve power seat elevation feature. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 power seat elevation feature. Our 
reviewer says that the services are not medically covered. Our physician reviewer found the requested item is a 
convenience item and not covered.  
 
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 power seat elevation feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power seat elevation 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.