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 state that all of the following basic criteria must be met for a power mobility device  to be covered. 
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. 
 
The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately 
fitted cane or walker. 
 
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 face-to-face encounter must be conducted within six (6) months prior to the order date on the WOPD for the 
PMD (base item). The 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. 
 
The written report of this encounter must be available upon request. 
 
Practitioners shall document the encounter in a detailed narrative note in their charts in the format that they use 
for other entries. The note must clearly indicate that a major reason for the visit was a mobility encounter. 
 
Many suppliers have created forms which have not been approved by CMS which they send to practitioners 
and ask them to complete. Even if the treating practitioner completes this type of form and puts it in his/her 
chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above. 
Suppliers are encouraged to help educate practitioners on the type of information that is needed to document a 
beneficiary's mobility needs. 
 
You can find these rules 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.