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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 Medicare National Coverage Determinations Manual, Section 280.3(B). The rules say that a Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage criteria for a power wheelchair are met and if: Criterion 1 or 2 is met; and Criteria 3 and 4 are met. 1. The beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair 2. The beneficiary uses a ventilator which is mounted on the wheelchair. 3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or 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. 4. 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. You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices (L33789) - Effective January 1, 2020. The rules say that positioning accessory (such as HCPCS E0955) are covered for a beneficiary who meets both of the following criteria: 1. The beneficiary has a manual wheelchair or a power wheelchair with sling/solid seat/back and the beneficiary meets the Medicare coverage criteria for it; and 2. The beneficiary has any significant postural asymmetries that are due to a covered diagnosis You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) - Effective January 1, 2020. The rules say that a power seating system (HCPCS E1007 and HCPCS E1012) - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests 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 above; 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 in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) - Effective January 1, 2020. The rules say that one example (not all inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed. You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) - Effective January 1, 2020.
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.