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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).The rules say that services that are not medically necessary are not covered. The rulesalso say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).The rules state that All of the following basic criteria (A-C) must be met for a power mobility device or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:Prevents the beneficiary from accomplishing an MRADL entirely, orPlaces the beneficiary atreasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; orPrevents the beneficiary from completing an MRADL within a reasonable time frame.The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.POWER WHEELCHAIRS:A power wheelchair is covered if:All of the basic coverage criteria (A-C) are met; andThe beneficiary does not meet coverage criterion D, E, or F for a POV; andEither criterion J or K is met; andCriteria L, M, N, and O are met; andAny coverage criteria pertaining to the specific wheelchair type (see below) are met.The beneficiary has the mental andphysical capabilities to safely operate the power wheelchair that is provided; orIf 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
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 -i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 -450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 -600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more.The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.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.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.If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage.A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if:The Group 3 criteria IV(A) and IV(B) are met; andThe Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).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.