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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 all of the following basic criteria (A-C) must be met for a power mobility device or a push-
rim activated power assist device 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 beneficiarys 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. 
 
The rules also say that a Group 3 power wheelchair (PWC) with Multiple Power Options (K0861, K0862, 
K0863, K0864) 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 
C. Criterion 1 or 2 is met; and 
D. Criteria 3 and 4 are met. 
   1. The beneficiary meets coverage criteria for a power tilt and recline seating system 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 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. The PT, OT, or practitioner may have no financial relationship with the 
supplier. 
   4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests 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 PT or 
OT or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the 
beneficiarys 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 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. 
 
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware 
(E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a 
chair or bed. 
 
Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories 
(L33792). 
 
The rules say that a non-expandable controller has the following features: 
- May have the ability to control up to 2 power seating actuators through the drive control (for example, 
seat elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators 
though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
- Can accommodate only an integral joystick or a standard proportional remote joystick 
- May allow for the incorporation of an attendant control 
 
An expandable controller is capable of accommodating one or more of the following additional functions: 
- Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
- Non-proportional input devices (e.g., sip and puff, head array, etc.) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power 
seating actuators though the Control Input Device would require the use of an additional component, E2310 or 
E2311.) 
An expandable controller may also be able to operate one or more of the following: 
- A separate display (i.e., for alternate control devices) 
- Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
- An attendant control 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual 
components of the harness are replaced, code K0108 should be used. 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
HCPCS code E1012 includes all components of the leg rest, including fixed angle footplates and foot 
platforms. Adjustable angle footplates coded K0040 (ADJUSTABLE ANGLE FOOTPLATE, EACH) are 
separately payable when provided with leg rests coded as E1012. 
Code E1028 is used for 
1. Swingaway hardware used with remote joysticks or touchpads, 
2. Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and 
3. Swingaway hardware for an indicator display box that is related to the multi-motor electronic 
connection codes E2310 or E2311. 
 You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
The rules say that a skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary 
who meets both of the following criteria: 
1. 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 
2. The beneficiary has either of the following (a or b): 
   a. 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 ICD-10 code list in the LCD-related Policy Article; or 
   b. 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. 
 
A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, 
E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who 
meets both of the following criteria: 
1. 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 
2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
   a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or 
   b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 
 
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note 
special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the 
LCD-related Policy Article.) 
 
A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or 
fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt 
and/or recline power seating system. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
The rules say that incontinence supplies are not covered because they are hygienic items that are non-reusable. 
You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.1. 
 
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.