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 that all of the following basic criteria (A-C) must be met for a power mobility device: 
 
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 beneficiarys 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. 
The beneficiary is able to: 
        Safely transfer to and from a POV, and 
        Operate the tiller steering system, and 
        Maintain postural stability and position while operating the POV in the home. 
 
The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are 
sufficient for safe mobility using a POV in the home. 
 
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
 
The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class POV  i.e., a Heavy Duty POV is 
covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary 
weighing 428 - 600 pounds. 
 
Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the beneficiary 
will use it in the home. 
 
The beneficiary has not expressed an unwillingness to use a POV in the home. 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. 
 
You can find this information in the 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.