Appeal type: unknown
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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that 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. Power Wheelchair Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage. Armrests. There is no separate billing/payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided (K0015). Adjustable height armrests (E0973, K0020) may be billed separately. An expandable controller is capable of accommodating one or more of the following additional functions: -Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.); -Non-proportional input devices (e.g., sip and puff, head array, etc.); -Operate 3 or more powered seating actuators through the drive control.; -A separate display (i.e., for alternate control devices); -Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control); -An attendant control. 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. You can find this rule in the Local Coverage Article for Wheelchair Options/Accessories, A52504 (eff 01/01/20). The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for equipment that is primarily and customarily used for nonmedical purposes, or equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A). The Plan contract says that the Plan covers items and services in accordance with Medicare rules.