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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 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 rules also 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 also 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.
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:
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, inperson
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.
III. 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:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. 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.
2. The beneficiary uses a ventilator which is mounted on the wheelchair.
3. 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.
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, inperson
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.
IV. A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854,
K0855) is covered if:
A. All of the coverage criteria (a)-(e) for a PWC are met; and
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital
skeletal deformity; and
C. 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
D. 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.
V. 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:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. 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 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.