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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).
FACE-TO-FACE ENCOUNTER:
The face-to-face encounter must be conducted within six (6) months prior to the order date on the Written
Order prior to delivery for the PMD (base item).
The report should provide pertinent information about the following elements, but may include other details.
Each element would not have to be addressed in every evaluation.
-History of the present condition(s) and past medical history that is relevant to mobility needs
-Symptoms that limit ambulation
-Diagnoses that are responsible for these symptoms
-Medications or other treatment for these symptoms
-Progression of ambulation difficulty over time
-Other diagnoses that may relate to ambulatory problems
-How far the beneficiary can walk without stopping
-Pace of ambulation
-What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used
-What has changed to now require use of a power mobility device
-Ability to stand up from a seated position without assistance
-Description of the home setting and the ability to perform activities of daily living in the home
-Physical examination that is relevant to mobility needs
-Weight and height
-Cardiopulmonary examination
-Musculoskeletal examination
-Arm and leg strength and range of motion
-Neurological examination
-Gait
-Balance and coordination
The face-to-face 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. You
can find this information 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).
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.