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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 persons 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, Publication 
100-03, 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 (K0824) 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 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. 
 
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 beneficiarys 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 beneficiarys 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 beneficiarys 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 beneficiarys weight. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Power Mobility Devices 
(L33789). 
 
The rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your 
home may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of 
institution. However, an institution may not be considered your home if it is an acute hospital or a skilled 
nursing facility (SNF). You can find these rules in the Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1(D). 
 
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.