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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: 
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: 
o Prevents the beneficiary from accomplishing an MRADL entirely, or 
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
o 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. 
o 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. 
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating 
options, and other appropriate non-powered accessories. 
 
III. A Group 2 Multiple Power Option PWC is covered if all of the coverage criteria for a PWC are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met. 
1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and 
Accessories policy) and the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, 
such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair 
evaluations and that documents the medical necessity for the wheelchair and its special features (see 
Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the 
supplier. 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional 
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
 
IV. A Group 3 PWC with no power options is covered if:  
A. All of the coverage criteria (a)-(e) for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity 
V. A Group 3 PWC with Multiple Power Options (K0862) is covered if:  
A. The Group 3 criteria IV(A) and IV(B) are met; and 
B. The Group 2 Multiple Power Options (criteria III[A] and III[B]) (respectively) are met. 
 
You can find this rule in the Local Coverage Determination for Power Mobility Devices, L33789 (eff 
01/01/20). 
 
 
 
 
The rules say that a power seating system ? tilt only, recline only, or combination tilt and recline ? with or 
without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices 
LCD; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical 
therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in 
rehabilitation wheelchair evaluations of the beneficiary?s seating and positioning needs. The PT, OT, 
or practitioner may have no financial relationship with the supplier; and 
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional 
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight 
shift; or 
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
6. The power seating system is needed to manage increased tone or spasticity. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination for Wheelchair Options/Accessories, L33792 (eff 
01/01/20).  
The rules say that codes E2310 and E2311 describe the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the 
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function 
has been selected. 
An expandable controller is capable of accommodating one or more of the following additional functions: 
&#61623; Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, 
head control, etc.) 
&#61623; Non-proportional input devices (e.g., sip and puff, head array, etc.) 
&#61623; Operate 3 or more powered seating actuators through the drive control. 
&#61623; A separate display (i.e., for alternate control devices) 
&#61623; Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
&#61623; An attendant control 
You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, A52504 (eff 
01/01/20). 
 
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.