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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 state that all of the following basic criteria (A-C) must be met for a power mobility device or a pushrim
activated power assist device to be covered. Additional coverage criteria for specific devices are listed
below.

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.

A power wheelchair (PWC) is covered if:
a. all of the above basic coverage criteria (A-C) are met; and
b. The beneficiary does not meet coverage criteria for a power operated vehicle (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.

If a PWC will be used inside the home and if coverage criteria are not met, it will be denied as not reasonable
and necessary. If a PWC will only be used outside the home, it will be non-covered. A Group 2 Single Power
Option PWC is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard
proportional joystick.
2. The beneficiary meets coverage criteria for a power tilt, or a power recline seating system
and the system is being used on the wheelchair.
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified
medical professional, such as a physical therapist (PT) or occupational therapist (OT), or
practitioner who has specific training and experience in rehabilitation wheelchair evaluations
and that documents the medical necessity for the wheelchair and its special features. The PT,
OT, or practitioner may have no financial relationship with the supplier.
4. 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.

A Group 2 Multiple Power Option PWC is covered if all of the coverage criteria (a)-(e) for a PWC are met and
if:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. The beneficiary meets coverage criteria for a power tilt and recline seating system and the
system is being used on the wheelchair.
2. The beneficiary uses a ventilator which is mounted on the wheelchair.
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified
medical professional, such as a PT or OT, or practitioner who has specific training and
experience in rehabilitation wheelchair evaluations and that documents the medical necessity
for the wheelchair and its special features. The PT, OT, or practitioner may have no financial
relationship with the supplier.
4. 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.

A Group 3 PWC with no power options is covered if:
A. All of the coverage criteria (a)-(e) for a PWC are met; and
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital
skeletal deformity; and
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical
professional, such as a PT or OT, or practitioner who has specific training and experience in
rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair
and its special features. The PT, OT, or practitioner may have no financial relationship with the
supplier; and
D. 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.
A Group 3 PWC with Single Power Option or with Multiple Power Options is covered if:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. The Group 2 Single Power Option or Multiple Power Options (respectively) are met.

You can find these rules in Local Coverage Determination (LCD) Power Mobility Devices (L33789).

The rules state that a power seating system - tilt only, recline only, or combination tilt and recline - with or
without power elevating leg rests 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; 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 practitioner who has specific training and
experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning
needs. The PT, OT, or practitioner 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.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

Up to two batteries at any one time are allowed if required for a power wheelchair. One example (not allinclusive)
of a covered indication for swing away, retractable, or removable hardware (E1028) would be to
move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed. You can
find these rules 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 these rules in Local Coverage Article (LCA)
Wheelchair Options/Accessories Policy Article (A52504).

The rules state that a skin protection seat cushion is covered for a beneficiary who meets both of the following
criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the
beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has either of the following (a or b):
a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the
seating surface
b. Absent or impaired sensation in the area of contact with the seating surface or inability to
carry out a functional weight shift.
A positioning seat cushion, positioning back cushion, and positioning accessory are covered for a beneficiary
who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the
beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has any significant postural asymmetries that are due to certain diagnoses.

A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. A
headrest is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or fully reclining
back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline
power seating system. You can find these rules in Local Coverage Determination (LCD) Wheelchair Seating
(L33312).

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).

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.