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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 medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).
The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power
standing feature, it will be denied as non-covered.
A power seat elevation system (E2300) includes: a motor and related electronics with or without variable speed
programmability; a switch control which is independent of the power wheelchair drive control interface; any
hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of
at least 6 inches.
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and
with complete replacement of the expandable controller. Code K0108 must not be used for any component or
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual
components of the harness are replaced, code K0108 should be used.
You can find this information in Medicare's Local Coverage Article: Wheelchair Options/Accessories - Policy
Article (A52504).
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for:
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.