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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 Medicare National Coverage Determinations Manual, Section 280.3(B).
The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility
limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789 (eff 1/1/17).
The rules say that a power seating system - tilt only, recline only, or combination tilt and recline - with or
without power elevating leg rests 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: Wheelchair Options/Accessories - Policy Article (A52504) -
Effective January 1, 2020.
The rules say that one example (not all-inclusive) of a covered indication for swing-away, 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 rule in Local Coverage Determination (LCD):
Wheelchair Options/Accessories (L33792) - Effective January 1, 2020.
The rules say that a general use seat cushion (E2601) is covered for a beneficiary who has a manual wheelchair
or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the beneficiary
does not have a covered wheelchair, then the cushion will be denied as not reasonable and necessary. If the
beneficiary has a POV or a power wheelchair with a captain's chair seat, the cushion will be denied as not
reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating
(L33312) - 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.