Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection device (E2310). We also decided that the 
Plan does not have to pre-approve calf pad replacements (E0995), footplate accessories (K0108), and a seat 
liner (K0108).   

You asked the Plan to pre-approve a connection device, replacement pads, footplate accessories, and a seat 
liner. You say that the accessories are medically necessary. The Plan denied your request. The Plan says that 
that the requested items are not medically necessary. 
 
We decided that the Plan has to pre-approve an electronic connection device (E2310).  
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. 
 
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 device. Our 
reviewer says that the connection device is medically necessary. Our physician reviewer found that the enrollee 
is non-ambulatory and requires a power wheelchair for mobility and performing his basic daily activities. The 
enrollee cannot perform pressure relief independently due to weakness and requires a power wheelchair with 
power tilt for adequate pressure relief and positioning. The complexity of his seating and positioning needs 
necessitates a more complex power wheelchair base. The electronic connection is necessary to operate the 
Group 3 power wheelchair base and the power tilt option.  
 
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 device have been met. Therefore, we decided that the 
Plan has to pre-approve an electronic connection device (E2310).  
 
We also decided that the Plan does not have to pre-approve calf pad replacements (E0995), footplate 
accessories (K0108), and a seat liner (K0108). 
 
The Plan follows Medicare rules. Medicare rules say that miscellaneous options, accessories, or replacement 
parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be 
coded K0108. The rules also say that wheelchair seat and back cushion codes are all-inclusive. 
 
The requested calf pad replacements are not able to be requested for initial use. The requested footplate 
accessories are considered unbundled, and the correct code was already approved during the appeal review 
process. The seat liner is not covered as all the necessary components of the seat cushion were already 
approved. Therefore, we decided that the Plan does not have to pre-approve calf pad replacements (E0995), 
footplate accessories (K0108), and a seat liner (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.