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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). All of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: -Prevents the beneficiary from accomplishing an MRADL entirely, or -Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or -Prevents the beneficiary from completing an MRADL within a reasonable time frame. B. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. -Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. -An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories. You can find these rule in Local Coverage Determination (LCD): Power Mobility Devices (L33789). Home Assessment: Prior to or at the time of delivery of a power operated vehicle or power wheelchair, 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 Local Coverage Determination (LCD): Power Mobility Devices (L33789). Specialty Evaluation: The specialty evaluation that is required for beneficiary's who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 PWC, or a push-rim activated power assist device is in addition to the requirement for the face-to-face encounter. The specialty evaluation provides detailed information explaining why each specific option or accessory - i.e., power seating system, alternate drive control interface, or push-rim activated power assist - is needed to address the beneficiary's mobility limitation. There must be a written report of this evaluation available on request. You can find this information in 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.