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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 as a condition of payment pursuant to 42 CFR 410.38, Power Mobility Devices (PMDs) 
require a standard written order prior to delivery (WOPD) for the base item. If the supplier does not receive the 
order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary. 
 
The WOPD for the base item may only be written after the completion of the face-to-face encounter 
requirements. Pursuant to the Social Security Act, Title XVIII, 1834(a)(1)(E)(iv), the treating practitioner who 
completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the 
PMD (base item). 
 
A supplier may provide a template to the treating practitioner for their use in creating the WOPD for the base 
item. Such a template may list the elements of a WOPD, but the supplier must not fill in or complete any of 
these elements. 
 
An SWO is required prior to claim submission for all options, accessories, and/or supplies that are separately 
billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by someone 
other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for separately 
billed options, accessories, and/or supplies, a treating practitioner must review and sign the order. 
 
The treating practitioner who reviews and signs the SWO for separately billable options, accessories, and/or 
supplies does not need to be the same treating practitioner who completed the WOPD for the PMD base and 
conducted the face-to-face encounter. In this situation, the treating practitioner who orders the options, 
accessories, and/or supplies must: 
 
    Verify that a qualifying face-to-face encounter occurred within 6-months prior to the date of the WOPD for 
the base item; and, 
    Have documentation of the qualifying face-to-face encounter that was conducted for the base item; 
    Review and sign their order. 
 
Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for 
additional information. 
 
FACE-TO-FACE ENCOUNTER: 
 
The face-to-face encounter must be conducted within six (6) months prior to the order date on the WOPD for 
the PMD (base item). 
 
The report of the face-to-face encounter (see Policy Article) should provide information relating to the 
following questions. 
 
The report should provide pertinent information about the following elements, but may include other details. 
Each element would not have to be addressed in every evaluation. 
 
    History of the present condition(s) and past medical history that is relevant to mobility needs 
        Symptoms that limit ambulation 
        Diagnoses that are responsible for these symptoms 
        Medications or other treatment for these symptoms 
        Progression of ambulation difficulty over time 
        Other diagnoses that may relate to ambulatory problems 
        How far the beneficiary can walk without stopping 
        Pace of ambulation 
        What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used 
        What has changed to now require use of a power mobility device 
        Ability to stand up from a seated position without assistance 
        Description of the home setting and the ability to perform activities of daily living in the home 
    Physical examination that is relevant to mobility needs 
        Weight and height 
        Cardiopulmonary examination 
        Musculoskeletal examination 
            Arm and leg strength and range of motion 
        Neurological examination 
            Gait 
            Balance and coordination 
 
The evaluation should be tailored to the individual beneficiary's conditions. The history should paint a picture 
of the beneficiary's functional abilities and limitations on a typical day. It should contain as much objective 
data as possible. The physical examination should be focused on the body systems that are responsible for the 
beneficiary's ambulatory difficulty or impact on the beneficiary's ambulatory ability. 
 
The written report of this encounter must be available upon request. 
 
Practitioners shall document the encounter in a detailed narrative note in their charts in the format that they use 
for other entries. The note must clearly indicate that a major reason for the visit was a mobility encounter. 
 
Many suppliers have created forms which have not been approved by CMS which they send to practitioners 
and ask them to complete. Even if the treating practitioner completes this type of form and puts it in his/her 
chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above. 
Suppliers are encouraged to help educate practitioners on the type of information that is needed to document a 
beneficiary's mobility needs. 
 
Practitioners shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., 
pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of 
the beneficiary. Upon request, suppliers shall provide notes from prior visits to give a historical perspective of 
the progression of disease over time and to corroborate the information in the face-to-face encounter. 
 
If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the 
face-to-face encounter (see Policy Article), there must be a signed and dated attestation by the supplier or 
LCMP that the LCMP has no financial relationship with the supplier. (Note: Evaluations performed by an 
LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical 
information, but will not be considered as part of the face-to-face encounter by the treating practitioner.) 
 
Although beneficiaries who qualify for coverage of a power mobility device may use that device outside the 
home, because Medicare's coverage of a wheelchair or POV is determined solely by the beneficiary's mobility 
needs within the home, the encounter must clearly distinguish the beneficiary's abilities and needs within the 
home from any additional needs for use outside the home. 
 
SPECIALTY EVALUATION: 
 
The specialty evaluation that is required for beneficiary's who receive a Group 2 Single Power Option or 
Multiple Power Options PWC, any Group 3 PWC, or a push-rim activated power assist device is in addition to 
the requirement for the face-to-face encounter. The specialty evaluation provides detailed information 
explaining why each specific option or accessory i.e., power seating system, alternate drive control interface, 
or push-rim activated power assist is needed to address the beneficiary's mobility limitation. There must be a 
written report of this evaluation available on request. 
 
HOME ASSESSMENT: 
 
Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site 
evaluation of the beneficiary's home to verify that the beneficiary can adequately maneuver the device that is 
provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a 
written report of this evaluation available on request. 
 
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.