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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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
National Coverage Determinations Manual, Section 280.3(B).
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. If an attendant control (E2331) is provided in addition to a beneficiary-operated
drive control system, it will be denied as non-covered. You can find this information in the Local Coverage
Article: Wheelchair Options/Accessories - Policy Article (A52504).
A non-expandable controller has the following features:
May have the ability to control up to 2 power seating actuators through the drive control (for example, seat
elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the
Control Input Device would require the use of an additional component, E2310 or E2311.)
Can accommodate only an integral joystick or a standard proportional remote joystick
May allow for the incorporation of an attendant control
An expandable controller is capable of accommodating one or more of the following additional functions: Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) Non-proportional input devices (e.g., sip and puff, head array, etc.) Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) An expandable controller may also be able to operate one or more of the following: A separate display (i.e., for alternate control devices) Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) An attendant control Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present). For power wheelchairs which are capable of being upgraded to an expandable controller (K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller. A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual components of the harness are replaced, code K0108 should be used.
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.