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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 a power mobility device (K0861) is covered if the following are met: 
All of the basic coverage criteria (A-C) are met; and 
The beneficiary does not meet coverage criterion D, E, or F for a POV; and 
Either criterion J or K is met; and 
Criteria L, M, N, and O are met; and 
Any coverage criteria pertaining to the specific wheelchair type (see below) are 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 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. 
1. 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. 
2. 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: 
1. Safely transfer to and from a POV, and 
2. Operate the tiller steering system, and 
3. Maintain postural stability and position while operating the POV in the home. E. The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) 
are sufficient for safe mobility using a POV in the home. 
 
F. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the POV that is provided. 
 
G. The beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class POV  i.e., a Heavy 
Duty POV is covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty POV is covered 
for a beneficiary weighing 428  600 pounds. 
 
H. Use of a POV will significantly improve the beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
 
I. The beneficiary has not expressed an unwillingness to use a POV in the home. 
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. 
The rules also say that if the power wheelchair base is not covered, then related accessories will be denied. 
 
You can find these rules in 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.