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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 the beneficiary, the beneficiary's family or other caregiver, or a clinician, will usually initiate
the discussion and consideration of mobility assistive equipment (MAE) use. Sequential consideration of the
questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity
to restore the beneficiary's ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and
bathing in customary locations in the home. These questions correspond to the numbered decision points on the
accompanying flow chart. In individual cases where the beneficiary's condition clearly and unambiguously
precludes the reasonable use of a device, it is not necessary to undertake a trial of that device for that
beneficiary.
1. Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in
one or more MRADLs in the home? A mobility limitation is one that:
a. Prevents the beneficiary from accomplishing the MRADLs entirely, or,
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to
the attempts to participate in MRADLs, or,
c. Prevents the beneficiary from completing the MRADLs within a reasonable time frame.
2. Are there other conditions that limit the beneficiary's ability to participate in MRADLs at home?
a. Some examples are significant impairment of cognition or judgment and/or vision.
b. For these beneficiaries, the provision of MAE might not enable them to participate in MRADLs if the
comorbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with MAE.
3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the
additional provision of MAE will be reasonably expected to significantly improve the beneficiary's ability to
perform or obtain assistance to participate in MRADLs in the home?
a. A caregiver, for example a family member, may be compensatory, if consistently available in the
beneficiary's home and willing and able to safely operate and transfer the beneficiary to and from the
wheelchair and to transport the beneficiary using the wheelchair. The caregiver's need to use a wheelchair to
assist the beneficiary in the MRADLs is to be considered in this determination.
b. If the amelioration or compensation requires the beneficiary's compliance with treatment, for example
medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial
of MAE coverage if it results in the beneficiary continuing to have a significant limitation. It may be
determined that partial compliance results in adequate amelioration or compensation for the appropriate use of
MAE.
4. Does the beneficiary or caregiver demonstrate the capability and the willingness to consistently operate
the MAE safely?
a. Safety considerations include personal risk to the beneficiary as well as risk to others. The
determination of safety may need to occur several times during the process as the consideration focuses on a
specific device.
b. A history of unsafe behavior in other venues may be considered.
5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
a. The cane or walker should be appropriately fitted to the beneficiary for this evaluation.
b. Assess the beneficiary's ability to safely use a cane or walker.
6. Does the beneficiary's typical environment support the use of wheelchairs including scooters/power-operated
vehicles (POVs)?
a. Determine whether the beneficiary's environment will support the use of these types of MAE.
b. Keep in mind such factors as physical layout, surfaces, and obstacles, which may render MAE unusable
in the beneficiary's home.
7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home
to participate in MRADLs during a typical day? The manual wheelchair should be optimally configured
(seating options, wheelbase, device weight, and other appropriate accessories) for this determination.
a. Limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or
both upper extremities are relevant.
b. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair. The
appropriate type of manual wheelchair, i.e. light weight, etc., should be determined based on the beneficiary's
physical characteristics and anticipated intensity of use.
c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the
operation of a manual wheelchair.
d. Assess the beneficiary's ability to safely use a manual wheelchair.
NOTE: If the beneficiary is unable to self-propel a manual wheelchair, and if there is a caregiver who is
available, willing, and able to provide assistance, a manual wheelchair may be appropriate.
8. Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter?
a. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities. The
beneficiary must be able to maintain stability and position for adequate operation.
b. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the
operation of a POV.
c. Assess the beneficiary's ability to safely use a POV/scooter.
9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate
in one or more MRADLs?
a. The pertinent features of a power wheelchair compared to a POV are typically control by a joystick or
alternative input device, lower seat height for slide transfers, and the ability to accommodate a variety of
seating needs.
b. The type of wheelchair and options provided should be appropriate for the degree of the beneficiary's
functional impairments.
c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the
operation of a power wheelchair.
d. Assess the beneficiary's ability to safely use a power wheelchair.
NOTE: If the beneficiary is unable to use a power wheelchair, and if there is a caregiver who is available,
willing, and able to provide assistance, a manual wheelchair is appropriate. A caregiver's inability to operate a
manual wheelchair can be considered in covering a power wheelchair so that the caregiver can assist the
beneficiary.
You can find this information in Medicare's National Coverage Determination (NCD) for Mobility Assistive
Equipment (MAE) (280.3).
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.
POWER WHEELCHAIRS (K0013, 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):
A power wheelchair is covered if:
a. All of the basic coverage criteria (A-C) are met; and
b. The beneficiary does not meet coverage criterion D, E, or F for a POV; and
c. Either criterion J or K is met; and
d. Criteria L, M, N, and O are met; and
e. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
J. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is
provided; or
K. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is
unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to
safely operate the power wheelchair that is provided; and
L. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is
provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC - i.e., a
Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty PWC is
covered for a beneficiary weighing 428 - 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary
weighing 570 pounds or more.
M. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for
the operation of the power wheelchair that is provided.
N. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs
and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical
impairments, participation in MRADLs may require the assistance of a caregiver.
O. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.
If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not
reasonable and necessary.
If a PWC will only be used outside the home, see related Policy Article for information concerning
non-coverage.
I. 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).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.