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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 Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare
National Coverage Determinations Manual, Section 280.3(B).
The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0861) 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: Prevents
the beneficiary from accomplishing an MRADL entirely, or; Places the beneficiary at reasonably determined
heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or; 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. 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. You can
find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).
A power seating system - tilt only, recline only, or combination tilt and recline - with or without power
elevating leg rests 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; 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. If these criteria are not met, the power seating component(s) will be denied as not
reasonable and necessary.
You can find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories
(L33792).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.