Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that the written order prior to delivery (WOPD) for the base item may only be written after the
completion of the face-to-face encounter requirements. Pursuant to the Social Security Act, Title XVIII,
Section 1834(a)(1)(E)(iv), the treating practitioner who completes the face-to-face requirements must be the
same practitioner who writes the order/prescription for the PMD (base item). A supplier may provide a
template to the treating practitioner for their use in creating the WOPD for the base item. Such a template may
list the elements of a WOPD, but the supplier must not fill in or complete any of these elements. An Standard
Written Order (SWO) is required prior to claim submission for all options, accessories, and/or supplies that are
separately billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by
someone other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for
separately billed options, accessories, and/or supplies, a treating practitioner must review and sign the order.
The treating practitioner who reviews and signs the SWO for separately billable options, accessories, and/or
supplies does not need to be the same treating practitioner who completed the WOPD for the Power Mobility
Device (PMD) base and conducted the face-to-face encounter. In this situation, the treating practitioner who
orders the options, accessories, and/or supplies must: Verify that a qualifying face-to-face encounter occurred
within 6-months prior to the date of the WOPD for the base item; and, Have documentation of the qualifying
face-to-face encounter that was conducted for the base item; Review and sign their order. The face-to-face
encounter must be conducted within six (6) months prior to the order date on the WOPD for the PMD (base
item). The report of the face-to-face encounter (see Policy Article) should provide information relating to the
following questions. The report should provide pertinent information about the following elements but may
include other details. Each element would not have to be addressed in every evaluation. History of the present
condition(s) and past medical history that is relevant to mobility needs: Symptoms that limit ambulation;
Diagnoses that are responsible for these symptoms; Medications or other treatment for these symptoms;
Progression of ambulation difficulty over time; Other diagnoses that may relate to ambulatory problems; How
far the beneficiary can walk without stopping; Pace of ambulation; What ambulatory assistance (cane, walker,
wheelchair, caregiver) is currently used; What has changed to now require use of a power mobility device;
Ability to stand up from a seated position without assistance; Description of the home setting and the ability to
perform activities of daily living in the home. Physical examination that is relevant to mobility needs: Weight
and height; Cardiopulmonary examination; Musculoskeletal examination; Arm and leg strength and range of
motion; Neurological examination; Gait; Balance and coordination. Prior to or at the time of delivery of a POV
or power wheelchair (PWC), the supplier or practitioner must perform an on-site evaluation of the beneficiary's
home to verify that the beneficiary can adequately maneuver the device that is provided considering physical
layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation
available on request. You can find this information in Medicare's Local Coverage Determination (LCD): Power
Mobility Devices (L33789).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.