Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and positioning belt/safety belt/pelvic strap (E0978). We decided that the Plan does not 
have to pre-approve a hand or chin control interface (E2374).   
You asked the Plan to pre-approve an electronic connection (E2311), harness (E2313), expandable controller 
(E2377), positioning belt/safety belt/pelvic strap (E0978), and hand or chin control interface (E2374). You say 
that the enrollee does qualify for the requested power wheelchair. 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 says that payment of E2374, joystick, is included in the requested 
wheelchair base code for the group 3 power wheelchair, and a separate request for E2374 should be denied as 
unbundled. The Plan also says that a seat belt is already included with the power wheelchair, and a separate 
request for seat belt is denied as unbundled. 
 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and positioning belt/safety belt/pelvic strap (E0978).  
 
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, harness, 
expandable controller, positioning belt/safety belt/pelvic strap. Our reviewer says that the requested 
items/services are considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee is non-ambulatory and requires a power wheelchair for mobility and performing their basic daily 
activities. The enrollee cannot perform pressure relief independently due to upper extremity weakness and has 
a history of skin breakdown. The enrollee requires a power wheelchair with power tilt and recline for adequate 
pressure relief and positioning. Our reviewer found that the enrollee requires power elevating leg rests for 
positioning of their lower extremities and lower extremity edema. The complexity of the enrollee's 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. Our physician reviewer also found that the enrollee requires a positioning belt to stay safely 
positioned in the 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, harness, expandable controller, and positioning 
belt/safety belt/pelvic strap have been met. Therefore, we decided that the Plan has to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and positioning belt/safety belt/pelvic 
strap (E0978).  
 
We also decided that the Plan does not have to pre-approve a hand or chin control interface (E2374). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 hand or chin control interface 
(E2374). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is a lack of documentation regarding why the 
enrollee cannot operate the power wheelchair and power components with the joystick. Our reviewer also 
found that the enrollee is noted to have 2 to 3 out of 5 motor strength in the upper extremities and can assist 
with some activities of daily living. 
 
 
 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 hand or chin control interface have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hand or chin control interface (E2374). 
 
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.