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 say that a manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
    Criteria A, B, C, D, and E are met; and 
    Criterion F or G is met. 
 
    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: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
 
    The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use 
of the manual wheelchair that is provided. 
 
    Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
 
    The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
     The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home 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. 
 
    The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
 
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1037, E1038, E1039, E1161, 
K0002, K0003, K0004, K0005, K0006, K0007, K0008) 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
 
A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair 
(K0001) and if basic coverage criteria A-E and G above are met. 
 
A standard hemi-wheelchair (K0002) is covered when the beneficiary requires a lower seat height (17" to 18") 
because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion. 
 
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2): 
 
    Cannot self-propel in a standard wheelchair in the home; and 
 
    The beneficiary can and does self-propel in a lightweight wheelchair. 
 
A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in (1) or (2): 
 
    The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be 
performed in a standard or lightweight wheelchair. 
 
    The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, 
lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. 
 
A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is 
less than three months (e.g., post-operative recovery). You can find these rules in the Local Coverage 
Determination (LCD) Manual Wheelchair Bases L33788. 
 
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.