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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). A power wheelchair is covered if: a. All of the basic coverage criteria (A-C) are met; and b. The beneficiary does not meet coverage criterion D, E, or F for a POV; and c. Either criterion J or K is met; and d. Criteria L, M, N, and O are met; and e. Any coverage criteria pertaining to the specific wheelchair type (see below) are met. J. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or K. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and L. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC - i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 - 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more. M. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. N. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver. O. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home. You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789). POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1012): 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 physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or physician 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. You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). The rules state 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. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 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.