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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 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. 
 
    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: 
 
      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. 
 
    B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
    C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
use of the manual wheelchair that is provided. 
    D. 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. 
    E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the 
home. 
    F. 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. 
    G. 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 custom manual wheelchair base (K0008) is covered if, in addition to the general coverage 
criteria above, the specific configuration required to address the beneficiarys physical and/or functional 
deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of 
wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the 
individual construction of a unique individual manual wheelchair base is required. If K0008 is used to describe 
a prefabricated manual wheelchair base, even one that has been modified in any fashion, the claim will be 
denied for incorrect coding. Refer to the CODING GUIDELINES section of the related Policy Article for 
additional information about correct coding of K0008. You can find this information in Medicare's 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.