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 a manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
Criteria A, B, C, D, and E are met; and 
Criterion F or G is met. 
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: 
 
  1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
  2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
 
  3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane 
or walker. 
 
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use of 
the manual wheelchair that is provided. 
 
Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it on a regular basis in the home. 
 
The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. 
 
The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home 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. 
 
The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1037, E1038, E1039, E1161, 
K0002, K0003, K0004, K0005, K0006, K0007, K0008) 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
 
A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair 
(K0001) and if basic coverage criteria A-E and G above are met. 
 
A standard hemi-wheelchair (K0002) is covered when the beneficiary requires a lower seat height (17" to 18") 
because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion. 
 
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 
 
Cannot self-propel in a standard wheelchair in the home; and 
 
The beneficiary can and does self-propel in a lightweight wheelchair. 
 
A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in (1) or (2): 
 
The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be 
performed in a standard or lightweight wheelchair. 
 
The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight 
or hemi-wheelchair, and spends at least two hours per day in the wheelchair. 
 
A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is 
less than three months (e.g., post-operative recovery). You can find these rules in the Local Coverage 
Determination (LCD) Manual Wheelchair Bases L33788. 
 
The rules say that adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary 
requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends 
at least 2 hours per day in the wheelchair. 
 
A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611, E2612) are 
covered for a beneficiary who has a manual wheelchair or a power wheelchair with a sling/solid seat/back 
which meets Medicare coverage criteria. If the beneficiary does not have a covered wheelchair, then the 
cushion will be denied as not reasonable and necessary. If the beneficiary has a power operated vehicle (POV) 
or a power wheelchair with a captain's chair seat, the cushion will be denied as not reasonable and necessary. 
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of 
the following criteria: 
 
The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary 
meets Medicare coverage criteria for it; and 
 The beneficiary has either of the following (a or b): 
 
Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as 
reflected in a diagnosis code listed in Group 1 of the International Classification of Diseases (ICD)-10 code list 
in the LCD-related Policy Article; or 
 
Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional 
weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy 
Article. You can find these rules in the Local Coverage Determination (LCD) Wheelchair Seating L33312. 
 
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.