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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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:
1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as
toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
National Coverage Determinations Manual, Section 280.3(B).
The rules say a group 3 power wheelchair with multiple power options will be covered if:
1. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal
deformity; and
2. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical
professional, such as a physical therapist (PT) or occupational therapist (OT), or practitioner who has specific
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for
the wheelchair and its special features. The PT, OT, or practitioner may have no financial relationship with the
supplier; and
3. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive
Technology Society (RESNA)-certified Assistive Technology Professional (ATP) who specializes in
wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary; and
either
4. The beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being
used on the wheelchair; or
5. The beneficiary uses a ventilator which is mounted on the wheelchair.
You can find this rule at Local Coverage Determination (LCD) for Power Mobility Devices (L33789).
The rules say that a power seating system - tilt only, recline only, or combination tilt and recline - with or
without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility
Devices LCD; and
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical
therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in
rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or
practitioner may have no financial relationship with the supplier; and
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection
for the beneficiary.
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional
weight shift; or
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently
transfer from the wheelchair to bed; or
6. The power seating system is needed to manage increased tone or spasticity.
You can find this rule at Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L33792).
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.