Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics. We decided that the Plan does not have 
to pre-approve LED light, push handles, and medical necessities bag.  
 
You asked the Plan to pre-approve upgraded electronics, LED light, push handles, and medical necessities bag.. 
You say that the approved power wheelchair includes three power actuators. You also say that this is allowed 
per CMS Power Wheelchair Electronics Clarification. The Plan says that it is not medically necessary to 
control the power drives with a joystick. The Plan also says that the LED light, push handles, and medical 
necessities bag do not serve a medical purpose. 
 
We decided that the Plan has to pre-approve the upgraded electronics.  
 
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. Our reviewer 
says that the requested upgraded electronics are medically necessary. Our physician reviewer found the 
documentation indicates that the enrollee is 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. There is a history of skin breakdown. Power elevating leg rests are required for positioning of the 
lower extremities and lower extremity spasticity. 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. Therefore, the expandable controller (E2377) with harness (E2313) and electronic connection 
(E2311) is 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 have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve LED light, push handles, and medical 
necessities bag. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The 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 LED light, push handles, and medical necessities bag. 
 
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.