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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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility
limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17).
The rules also say that a Group 3 power wheelchair with Single Power Option (K0856, K0857, K0858, K0859,
K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if the enrollee meets the
coverage criteria for power tilt or power recline seating system. This requires the enrollee to either
a. be at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
b. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently
transfer from the wheelchair to bed; or
c. The power seating system is needed to manage increased tone or spasticity.
You can find more information at Local Coverage Determination (LCD): Wheelchair Options/Accessories
(L33792).
The rules also say that a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614,
E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered
for a beneficiary who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the
beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b):
a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or
b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article.
You can find more information at Local Coverage Determination (LCD): Wheelchair Seating (L33312).
The rules also say that one example (not all-inclusive) of a covered indication for swing away, retractable, or
removable hardware (E1028) would be to move the component out of the way so that a beneficiary can
perform a slide transfer to a chair or bed. You can find this rule at Local Coverage Determination (LCD):
Wheelchair Options/Accessories (L33792).
The rules also say that Codes E2310 and E2311 describe electronic components that allow the patient to control
two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or
nonproportional interface:
a. Power tilt
b. Power recline, with or without shear reduction
c. Combination power tilt and recline, with or without shear reduction
d. Power leg elevation with or without articulation, power center mount elevating foot platform with or
without articulating properties.
You can find this rule at Local Coverage Article: Power Mobility Devices - Policy Article (A52498).
A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611, E2612) are
covered for a beneficiary who has a manual wheelchair or a power wheelchair with a sling/solid seat/back
which meets Medicare coverage criteria. If the beneficiary does not have a covered wheelchair, then the
cushion will be denied as not reasonable and necessary. If the beneficiary has a POV or a power wheelchair
with a captain's chair seat, the cushion will be denied as not reasonable and necessary.
You can find this rule at Local Coverage Determination (LCD): Wheelchair Seating (L33312).
The rules also say that 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 rule at 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.