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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 Medicare will pay for durable medical equipment that is needed for use in the home. Your home may be a dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility (SNF). You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). The rules say a manual wheelchair for use inside the home (E1037 - E1039, E1161, K0001 - K0009) is covered if: Criteria A, B, C, D, and E are met; and Criterion F or G is met. A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: 1. Prevents the beneficiary from accomplishing an MRADL entirely, or 2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or 3. Prevents the beneficiary from completing an MRADL within a reasonable time frame. B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home. E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. You can find this information in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 1. Cannot self-propel in a standard wheelchair in the home; and 2. The beneficiary can and does self-propel in a lightweight wheelchair
You can find this information in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788).
If the manual wheelchair is only for use outside the home, it will be denied as noncovered, no benefit, as the DME benefit requires use within the home for coverage eligibility.
You can find this rule in Local Coverage Article: Manual Wheelchair Bases - Policy Article (A52497).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.