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 a personal item hook 
(K0108).  
 
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), and personal item hook (K0108). 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. The Plan also says that bag hooks do not serve a primary medical purpose. 
 
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 you require power 
elevating leg rests for positioning of your lower extremities. The complexity of your seating and positioning 
needs necessitates a more complex group 3 power wheelchair base. Our reviewer found that 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 a personal item hook (K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The personal item hook (K0108) at issue in this appeal does not serve a purpose that is primarily medical in 
nature. This item is available to the general public and would be helpful even to those who are not sick or 
injured. Based on this information, we decided that Medicare rules for coverage of a personal item hook 
(K0108) have not been met. Therefore, we decided that the Plan does not have to pre-approve a personal item 
hook (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.