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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 Group 2 Multiple Power Option PWC (K0841, K0842, K0843) 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 (see Wheelchair Options 
and Accessories policy) 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 (see 
Documentation Requirements section). 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. 
You can find these rules 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. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of 
the following criteria: 
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 
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 as 
reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or 
b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a 
functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-
related Policy Article. 
You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
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.