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 all of the following basic criteria (A-C) must be met for a power mobility device (K0800, 
K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, 
K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, 
K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, 
K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, 
K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898) or a push-rim activated power assist device 
(E0986) to be covered. Additional coverage criteria for specific devices are listed below. 
A. 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:  
o Prevents the beneficiary from accomplishing an MRADL entirely, or 
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
o Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiary?s mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
C. 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.  
o 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. 
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device 
weight, seating options, and other appropriate nonpowered accessories. 
POWER OPERATED VEHICLES (K0800, K0801, K0802, K0806, K0807, K0808, K0812): 
 
A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met. 
D. The beneficiary is able to:  
o Safely transfer to and from a POV, and 
o Operate the tiller steering system, and 
o Maintain postural stability and position while operating the POV in the home. 
E. The beneficiary?s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
F. The beneficiary?s home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided.  
G. The beneficiary?s weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV ? i.e., a Heavy 
Duty POV is covered for a beneficiary weighing 285 ? 450 pounds; a Very Heavy Duty POV is covered 
for a beneficiary weighing 428 ? 600 pounds. 
H. Use of a POV will significantly improve the beneficiary?s ability to participate in MRADLs and the 
beneficiary will use it in the home. 
I. The beneficiary has not expressed an unwillingness to use a POV in the home. 
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable 
and necessary. 
 
Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. 
Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. 
 
If a POV will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 
POWER WHEELCHAIRS (K0013, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, 
K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, 
K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, 
K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, 
K0884, K0885, K0886, K0890, K0891, K0898): 
 
A power wheelchair is 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; and 
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 ? 
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. 
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. 
 
If a PWC will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 
ADDITIONAL CRITERIA FOR SPECIFIC TYPES OF POWER WHEELCHAIRS: 
I. A Group 1 PWC (K0813, K0814, K0815, K0816) or a Group 2 PWC (K0820, K0821, K0822, K0823, 
K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) for a 
PWC are met and the wheelchair is appropriate for the beneficiary?s weight. 
II. A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, 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; 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 legrests), it will be denied as not reasonable and necessary. 
You can find this 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.