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 a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests (E1012) 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. 

You can find this rule in Local Coverage Determination (LCD):Wheelchair Options/Accessories (L33792) - Effective January 1, 2020. 

The rules say that 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. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following: 

-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 

You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective January 1, 2020. 

The rules say that power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests. The unit of service of code E1010 is a pair. The unit of service for code E1012 is each. You can find this rule in the Local Coverage Article (LCA) - Wheelchair Options/Accessories (A52504) - Effective January 1, 2020.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.