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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 to be 
covered. 
 
    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. 
 
As a condition of payment pursuant to 42 CFR 410.38, Power Mobility Devices (PMDs) require a standard 
written order prior to delivery (WOPD) for the base item. If the supplier does not receive the order/prescription 
for the base item prior to delivery, the claim will be denied as not reasonable and necessary. 
 
The WOPD for the base item may only be written after the completion of the face-to-face encounter 
requirements. Pursuant to the Social Security Act, Title XVIII, 1834(a)(1)(E)(iv), the treating practitioner who 
completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the 
PMD (base item). The face-to-face encounter must be conducted within six (6) months prior to the order date 
on the WOPD for the PMD (base item). 
 
You can find these rules and full coverage criteria in Local Coverage Determination (LCD): Power Mobility 
Devices (L33789). 
 
The rules also say that replacement refers to the provision of an identical or nearly identical item.  Situations 
involving the provision of a different item because of a change in medical condition are not addressed in this 
section. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or 
irreparable damage.  Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  
A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm 
the medical necessity of the item.  
 
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot 
be identified.  Replacement of equipment due to irreparable wear takes into consideration the reasonable useful 
lifetime of the equipment.  If the item of equipment has been in continuous use by the patient on either a rental 
or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of 
equipment.  Replacement may be reimbursed when a new physician order and/or new CMN, when required, is 
needed to reaffirm the medical necessity of the item. 
 
The reasonable useful lifetime of durable medical equipment is determined through program instructions.  In 
the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime of 
equipment, but in no case can it be less than 5 years.  Computation of the useful lifetime is based on when the 
equipment is delivered to the beneficiary, not the age of the equipment.  Replacement due to wear is not 
covered during the reasonable useful lifetime of the equipment.  
 
You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
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.