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 state that a Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the
coverage criteria (a)-(e) for a PWC 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 (see Wheelchair Options
and Accessories policy) 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 (see
Documentation Requirements section). 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 these rules in Local Coverage Determination (LCD): Power Mobility Devices (L33789).
A power seating system - 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 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.
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.
You can find these rules in Local Coverage Determination (LCD): 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.