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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 CFR 422.101.The rules say that a commode is covered when the beneficiary is physically incapable of utilizingregular toilet facilities. This would occur in the following situations:1. The beneficiary is confined to a single room, or2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or3. The beneficiary is confined to the home and there are no toilet facilities in the home.You can find this rule in Local Coverage Determination (LCD): Commodes (L33736) -Effective July 1, 2017.The rules say that a commode chair with detachable arms (E0165) is covered ifthe detachable arms feature is necessary to facilitate transferring the beneficiary or if the beneficiary has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Commodes (L33736) -Effective July 1, 2017.The rules say that a standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of the following criteria (1-3) are met:1. Thebeneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.A mobility limitation is one that:a. Prevents the beneficiary from accomplishing the MRADL entirely, orb. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL, orc. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and2. The beneficiary is able to safely use the walker; and3. The functional mobility deficit can be sufficiently resolved with use of a walker.You can find this rule in Local Coverage Determination (LCD): Walkers (L33791) -Effective January 1, 2017.The rules say that a manual wheelchair for use inside the home (E1037 -E1039, E1161, K0001 -K0009) is covered if:Criteria A, B, C, D, and E are met; andCriterion F or G is met.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:1. Prevents the beneficiary from accomplishing an MRADL entirely, or2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.E. The beneficiary has not expressed an unwillingness to use the manual wheelchairthat is provided in the home.F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home 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.G. The beneficiary has a caregiverwho is available, willing, and able to provide assistance with the wheelchair.You can find this rule in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) -Effective January 1, 2017.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.