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 state that equipment which the enrollee owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. If the item of equipment has been in continuous use by the enrollee on either a rental or purchase basis for the equipment's useful lifetime, the enrollee may elect to obtain a new piece of equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section 110.2 for Repairs, Maintenance, Replacement, and Delivery.
The rules say that power wheelchairs are covered if: a) All of the basic coverage criteria (A-C) are met; and b) The beneficiary does not meet coverage criterion D, E, or F for a POV; c) Either criterion J or K is met; and d) Criteria L, M, N, and O are met; and e) Any coverage criteria pertaining to the specific wheelchair type (see below) are met. J. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or K. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and L. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC M. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. N. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver. O. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.
If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not reasonable and necessary. Therefore, the Health Plan will uphold the referral request because based on the review of the medical records the member does not meet criteria J or K. The recommendation from DME Physical Therapist is that while repairs to the member's current Power Wheelchair are medically necessary the member needs to complete a Cognitive assessment to determine if the member is capable of operating the power wheelchair safely.
You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices (L33789).