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 state that 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 beneficiarys weight. 
 
    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: 
        Criterion 1 or 2 is met; and 
        Criteria 3 and 4 are met. 
            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). 
            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. 
            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. 
            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. 
 
    A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage criteria 
(a)-(e) for a PWC are met and if: 
        Criterion 1 or 2 is met; and 
        Criteria 3 and 4 are met. 
            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. 
            The beneficiary uses a ventilator which is mounted on the wheelchair. 
            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. 
            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 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be 
denied as not reasonable and necessary. 
 
    A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) is 
covered if: 
        All of the coverage criteria (a)-(e) for a PWC are met; and 
        The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity; and 
        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; and 
        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 3 PWC is provided and if criteria (IV)(A)  (IV)(D) are not met, it will be denied as not 
reasonable and necessary. 
 
    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; and 
        The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and 
III[B]) (respectively) are met. 
 
    If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or 
(V)(B) is not met, it will be denied as not reasonable and necessary. 
 
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.