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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 CFR 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; and4.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).II. A Group 2 Single Power Option PWC (K0835 -K0840) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:A. Criterion 1 or 2 is met; andB. 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 (includingbut not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating legrests), it will be denied as not reasonable and necessary.III. Group 2 Multiple Power Option PWC (K0841-K0843) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:A. Criterion 1 or 2 is met; andB. Criteria 3 and 4 are met.1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and Accessories policy) and the system is being used on the wheelchair.2. The beneficiary uses a ventilator which is mounted on the wheelchair.3. 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.
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 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be denied as not reasonable and necessary. You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789)POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1012): A power seating system -tilt only, recline only, or combination tilt and recline -with or without power elevating legrests 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; and2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and3. 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 inthe 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; or5. The beneficiary utilizes intermittent catheterization for bladder management andis unable to independently transfer from the wheelchair to bed; or6. 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).If youwant to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules