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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 state 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. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this rule in the Local Coverage Determination for Wheelchair Options/Accessories, L33792 (eff 
01/01/20). 
 
The rules say that a Group 2 Single Power Option PWC 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 leg rests), it will be denied as not reasonable and necessary. 
 
A Group 3 PWC with no power options is covered if:  
A. All of the coverage criteria 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. 
 
A Group 3 PWC with Multiple Power Options (K0862) 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. 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination for Power Mobility Devices, L33789 (eff 
01/01/20). 
 
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. 
? 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 the Local Coverage Article for Wheelchair Options/Accessories, A52504 (eff 
01/01/20). 
 
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.