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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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). The rules say that as a condition of payment pursuant to 42 CFR 410.38, Power Mobility Devices (PMDs) require a standard written order prior to delivery (WOPD) for the base item. If the supplier does not receive the order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary. The WOPD for the base item may only be written after the completion of the face-to-face encounter requirements. Pursuant to the Social Security Act, Title XVIII, Section 1834(a)(1)(E)(iv), the treating practitioner who completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the PMD (base item). A supplier may provide a template to the treating practitioner for their use in creating the WOPD for the base item. Such a template may list the elements of a WOPD, but the supplier must not fill in or complete any of these elements. An SWO is required prior to claim submission for all options, accessories, and/or supplies that are separately billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by someone other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for separately billed options, accessories, and/or supplies, a treating practitioner must review and sign the order. The treating practitioner who reviews and signs the SWO for separately billable options, accessories, and/or supplies does not need to be the same treating practitioner who completed the WOPD for the PMD base and conducted the face-to-face encounter. In this situation, the treating practitioner who orders the options, accessories, and/or supplies must: Verify that a qualifying face-to-face encounter occurred within 6-months prior to the date of the WOPD for the base item; and, Have documentation of the qualifying face-to-face encounter that was conducted for the base item; Review and sign their order. The evaluation should be tailored to the individual beneficiary's conditions. The history should paint a picture of the beneficiary's functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the beneficiary's ambulatory difficulty or impact on the beneficiary's ambulatory ability. HOME ASSESSMENT: Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request. You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices (L33789).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.