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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 pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for: 1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules say that 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. 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
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable
speed programmability; a switch control which is independent of the power wheelchair drive control interface;"
"A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or
without variable speed programmability which allows the legrest to be raised and lowered independently of the
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with
the power tilt and/or recline control(s).
You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article
(A52504).
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.