Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve upgraded electronics, knee support/abductor, and knee 
support hardware. We decided that the Plan does not have to pre-approve power standing feature, and 
essentials box with lights.  
 
You asked the Plan to pre-approve upgraded electronics, knee support/abductor, knee support hardware, power 
standing feature, and essentials box with lights. You say that this is medically necessary for the enrollee. The 
Plan says that the essentials box with lights does not serve a medical purpose. The Plan says that the upgraded 
electronics are not medically necessary and cannot be covered. The Plan says that a power standing system 
does not serve a medical purpose and cannot be covered. The Plan says that the knee pads do not serve a 
medical purpose and cannot be covered. The Plan also says that the lateral cushion mount hardware is already 
included with the requested cushions and cannot be requested separately. 
 
We decided that the Plan has to pre-approve upgraded electronics, knee support/abductor, and knee 
support hardware.  
 
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, knee 
support/abductor, knee support hardware, power standing feature, and essentials box with lights. Our reviewer 
says that the requested upgraded electronics, knee support/abductor, and knee support hardware are medically 
necessary. Our physician reviewer found the provided documentation supports that the enrollee is functionally 
non-ambulatory and requires a power wheelchair for mobility and performing daily activities. They cannot 
perform pressure relief independently due to upper extremity weakness and require a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. Power elevating leg rests are required for 
positioning of the lower extremities and lower extremity edema. The complexity of the enrollees 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 via a joystick. These components are required to operate 3 or more power options on a Group 3 
power wheelchair. The knee pads are also needed to prevent skin breakdown of the lower extremities and the 
mounting hardware is needed to support the positioning cushions. Therefore, the expandable controller (E2377) 
with harness (E2313) and electronic connection (E2311), knee pads and lateral cushion mount hardware 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, knee support/abductor, knee support hardware, power standing feature, and essentials box with lights have been met. Therefore, we decided that the Plan has to pre-
approve upgraded electronics, knee support/abductor, and knee support hardware.  
 
We also decided that the Plan does not have to pre-approve power standing feature, and essentials box 
with lights. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
These items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve power standing feature, and essentials box with lights. 
 
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.