Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve electrical connection between the wheelchair controller and 
two or more motors (E2311), expandable controller (E2377) and harness (E2313). We decided that the 
Plan does not have to pre-approve arm pads (K0108) hand strap (K0108).  
 
You asked the Plan to pre-approve electrical connection between the wheelchair controller and two or more 
motors (E2311), expandable controller (E2377) and harness (E2313) arm pads (K0108) hand strap (K0108).. 
You say that the enrollee meets the requirements for a K0861 Group 3 power wheelchair with power tilt and 
recline as requested. The Plan says that the upgraded electronics are not medically necessary. Arm pads are 
already included with the wheelchair and cannot be requested separately. The requested arm strap is unbundled 
and already included with E2209 arm trough. 
 
We decided that the Plan has to pre-approve electrical connection between the wheelchair controller and 
two or more motors (E2311), expandable controller (E2377) and harness (E2313).  
 
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 the upgraded electronics and 
wheelchair accessories. Our reviewer says that the requested upgraded electronics are considered medically 
necessary in this case. Our physician reviewer found the enrollee is functionally non-ambulatory and requires a 
power wheelchair for mobility and performing basic daily activities. The enrollee cannot perform pressure 
relief independently due to weakness and requires a power wheelchair with power tilt and recline for adequate 
pressure relief and positioning. The enrollee also requires power elevating leg rests for positioning of lower 
extremities and due to lower extremity lymphedema. 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, 
including, tilt, recline and elevating leg rests, via a joystick. Therefore, the expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) 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 the upgraded electronics and wheelchair accessories have been met.  Therefore, we decided that the Plan has to pre-approve electrical connection between the wheelchair controller 
and two or more motors (E2311), expandable controller (E2377) and harness (E2313).  
 
We also decided that the Plan does not have to pre-approve arm pads (K0108) hand strap (K0108). 
 
The Plan follows Medicare rules. Medicare rules say that each power wheelchair code is required to include all 
these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted): 
Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height 
armrests with arm pad are provided (K0015) adjustable height armrests (E0973, K0020) may be billed 
separately. 
 
In this case, we find that the requested arm pads are already included with the wheelchair and cannot be 
requested separately. The requested arm strap is also unbundled and already included with already approved 
E2209 arm trough. We looked at this the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arm pads (K0108) hand strap (K0108) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arm pads (K0108) hand strap (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.