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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).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The rules say that a group three power wheelchair with no power options is covered if: A. All of the standard coverage criteria for a power wheelchair are met 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. 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. You can find this rule in the Local Coverage Determination (LCD): Power Mobility Devices (L33789) - Effective January 1, 2020. The rules say that a group two single power option wheelchair is covered if all of the standard criteria for a power wheelchair are covered, 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.
You can find this rule in the Local Coverage Determination (LCD): Power Mobility Devices (L33789) - Effective January 1, 2020. The rules say that a group two multiple power options wheelchair is covered if all of the standard coverage criteria for a power wheelchair are met, and if: A. Criterion 1 or 2 is met, and B. 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. You can find this rule in the Local Coverage Determination (LCD): Power Mobility Devices (L33789) - Effective January 1, 2020. The rules say that a power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered 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.