Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve  a Q-Logic 3 Enhanced Display Kit (K0108), Quantum Backup 
Camera (K0108), Back Up Camera Track Mount Bracket (K0108), and Anterior Knee Block Assembly 
(K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says that a Q-Logic 3 Enhanced Display Kit cannot be 
approved, as the Q-Logic 3 with Mounting Bracket is already included with the requested expandable 
controller (E2377) and should not be covered separately. The Plan also says that the requested camera, 
mounting hardware, and anterior knee block assembly do not serve a medical purpose, and cannot be covered 
as they are not reasonable and necessary. 
 
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 durable medical equipment (DME). 
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 incoordination and requires a power wheelchair with power tilt and 
recline for adequate pressure relief and positioning. The complexity of the enrollee's seating and positioning 
needs necessitates a more complex group 3 power wheelchair base. The enrollee has impaired coordination and 
dystonia and cannot operate a standard control device given their upper extremity and hand incoordination 
from cerebral palsy. The enrollee is currently operating a power wheelchair with a head array and the advanced 
display with back up camera would allow the enrollee to operate the power wheelchair more safely and be more independent with mobility given their condition. The knee block is also required to keep the enrollee 
properly positioned in the wheelchair given their spasticity and seating needs. Therefore, the enhanced display 
kit (K0108), back up camera (K0108), back up camera mount bracket (K0108), and anterior knee block 
assembly (K0108) 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 durable medical equipment (DME) have been met. Therefore, we decided 
that the Plan has to pre-approve  a Q-Logic 3 Enhanced Display Kit (K0108), Quantum Backup Camera 
(K0108), Back Up Camera Track Mount Bracket (K0108), and Anterior Knee Block Assembly (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.