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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 cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:
1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such
as toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
National Coverage Determinations Manual, Section 280.3(B).
The rules say that II. A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) is
covered if all of the coverage criteria (a)-(e) 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 requires a drive control interface other than a hand or chin-operated standard
proportional joystick (examples include but are not limited to head control, sip and puff, switch control).
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see
Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the
wheelchair.
3.The beneficiary has had 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 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.
If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power
standing feature, or power elevating legrests), it will be denied as not reasonable and necessary.
III. A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage criteria (a)-(e) 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.
If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be
denied as not reasonable and necessary.
IV. A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) 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; and
C. 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; and
D. 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.
If a Group 3 PWC is provided and if criteria (IV)(A) - (IV)(D) are not met, it will be denied as not reasonable
and necessary.
V. A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power
Options (K0861, K0862, K0863, K0864) is covered if:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and
III[B]) (respectively) are met.
You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices
(L33789).
The rules say that Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.
POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007,
E1008, E1009, E1010, E1012):
A power seating system - tilt only, recline only, or combination tilt and recline - with or without power
elevating legrests 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.
One example (not all-inclusive) of a covered indication for swingaway, 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. One example (not all-inclusive) of a covered indication for swingaway, 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 information in Medicare's Local Coverage Determination (LCD):
Wheelchair Options/Accessories (L33792).
The rules say 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. A power seat elevation system (E2300) includes: a motor
and related electronics with or without variable speed programmability; a switch control which is independent
of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the
wheelchair base. It must provide a seat elevation of at least 6 inches. You can find this information in
Medicare's 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.