Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and custom fabricated wheelchair seat cushion (E2609). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and custom 
fabricated wheelchair seat cushion. You say that you need this wheelchair that the doctor prescribed for you 
since you need a recliner to go up and down, and to reach your cabinets. You also say that you need the 
wheelchair so you can easily move around, go to the car, and attend doctor's appointments. The Plan denied 
your request. The Plan says that although there are three approved power options on this wheelchair (tilt, 
recline and elevating leg rests), there is not a medical need to control these power options through the joystick. 
The Plan also says the notes do not clearly explain why a skin protection cushion, positioning cushion or skin 
protection and positioning cushion is not sufficient to meet the enrollee's needs, as required by Medicare 
guidelines. 
 
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, and custom fabricated wheelchair seat cushion. 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 and lower extremity spasticity. 
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. These components are 
required to operate 3 or more power options on a group 3 power wheelchair. Our physician reviewer also found 
that you require a custom seating system versus a standard pressure relieving cushion given your history of 
multiple pressure wounds and more complex seating requirements given his anatomical asymmetries. 
 
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 custom fabricated 
wheelchair seat cushion have been met. Therefore, we decided that the Plan has to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), and custom fabricated wheelchair seat 
cushion (E2609).  
 
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.