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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 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 say that all of the following basic criteria (A-C) must be met for a power mobility device (K0861) to 
be covered. 
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 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.  -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. 
D. The beneficiary is able to:  
-Safely transfer to and from a power operated vehicle (POV), and 
-Operate the tiller steering system, and 
-Maintain postural stability and position while operating the POV in the home. 
      E. The beneficiary's mental capabilities and physical capabilities 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. 
A power wheelchair (K0861) 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 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 power 
wheelchair (PWC). 
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. 
 
      II. A Group 2 Single Power Option PWC 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 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. 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, in-person involvement in 
the wheelchair selection for the beneficiary. 
     III. A Group 2 Multiple Power Option PWC 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 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. 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, in-person involvement in 
the wheelchair selection for the beneficiary. 
     IV. A Group 3 PWC with no power options 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. 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. 
     V. A Group 3 PWC with Single Power Option or with Multiple Power Options (K0861) 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 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. 
If the PWC base is not covered, then related accessories will be denied. 
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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.