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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 all of the following basic criteria (A-C) must be met for a power mobility device (K0800,
K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822,
K0823, K0824, K0825, K0826, K0827, K0828, K0829, 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, K0898) or a push-rim activated power assist device
(E0986) to be covered. Additional coverage criteria for specific devices are listed below.
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.
A Group 1 PWC (K0813, K0814, K0815, K0816) or a Group 2 PWC (K0820, K0821, K0822, K0823, K0824,
K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and
the wheelchair is appropriate for the beneficiary's weight.
You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices
(L33789).
The rules say that a sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable
from a power wheelchair base.
Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height
armrests with arm pad are provided (K0015). Adjustable height armrests (E0973, K0020) may be billed
separately. You can find this information in Medicare's Local Coverage Article: Wheelchair
Options/Accessories - Policy Article (A52504).
The rules say that adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary
requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends
at least 2 hours per day in the wheelchair. Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at
any one time are allowed if required for a power wheelchair. You can find this information in Medicare's Local
Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.