Appeal type: unknown
Decision: unknown

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 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).The rules say a manual wheelchair for use inside the home (E1037 -E1039, E1161, K0001 -K0009) is covered if: Criteria A, B, C, D, and E are met; and Criterion F or G is met.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:a. Prevents the beneficiary from accomplishing an MRADL entirely, orb. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; orc. Prevents the beneficiary from completing an MRADL within a reasonable time frame.B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home 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.G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.You can find this information in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788).A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in(1) or (2):1. The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.2. The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. A custom manual wheelchair is not reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).You can find this information in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788).Information showing that the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have been met must be present in the beneficiary's medical record. Information about whether the beneficiary's home can accommodate the wheelchair (Criterion C), also called the home assessment, must be fully documented in the medical record or elsewhere bythe supplier.You can find this information in Local Coverage Article: Manual Wheelchair Bases -Policy Article (A52497).