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 all of the following basic criteria (A-C) must be met for a power mobility device (K0800, 
K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, 
K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, 
K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, 
K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, 
K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898) or a push-rim activated power assist device 
(E0986) to be covered. Additional coverage criteria for specific devices are listed below. 
 
    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. 
    The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
 
    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. 
 
POWER WHEELCHAIRS (K0013, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, 
K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, 
K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, 
K0885, K0886, K0890, K0891, K0898): 
 
A power wheelchair is covered if: 
    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. 
 
    The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
    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 
    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. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
 
    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. 
 
    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. 
 
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. You can find these rules in the  Local Coverage 
Determination (LCD) Power Mobility Devices L33789. 
 
The rules say that up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are 
allowed if required for a power wheelchair. 
 
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware 
(E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a 
chair or bed. 
 
POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007, 
E1008, E1009, E1010, E1012): 
 
 A power seating system  tilt only, recline only, or combination tilt and recline  with or without power 
elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
 
    The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
    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 of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
    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. 
 
    The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
 
    The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
 
    The power seating system is needed to manage increased tone or spasticity. 
 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find these rules in the Local Coverage Determination (LCD) Wheelchair Options/Accessories 
L33792. 
 
The rules say that swingaway, retractable, or removable hardware (E1028) is non-covered if the primary 
indication for its use is to allow the beneficiary to move close to desks or other surfaces. If it is ordered for this 
indication, a GY modifier must be added to the code. 
 
Code E1028 is used for 
        Swingaway hardware used with remote joysticks or touchpads, 
        Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and 
        Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection 
codes E2310 or E2311. 
 
Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because 
swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a 
wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes 
swingaway hardware. 
 
A power tilt seating system (E1002) includes: a solid seat platform and a solid back; any frame width and 
depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; 
fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a 
switch control which is independent of the power wheelchair drive control interface; any hardware that is 
needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the 
following features: ability to tilt to greater than or equal to 20 degrees from horizontal; back height of at least 
20 inches; ability for the supplier to adjust the seat to back angle; ability to support beneficiary weight of at 
least 250 pounds. 
 
Coding for a power tilt system (E1002), power recline system (E1003, E1004 and E1005), and tilt/recline 
system (E1006, E1007 and E1008) are all-inclusive. Usage of K0108 to bill for additional heavy duty or 
bariatric features is considered unbundling and is not allowed. A power tilt seating system or power tilt and recline seating system which does not achieve a tilt of greater than 
or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair. Codes 
E1002, E1003, E1004, E1005, E1006, E1007, E1008 must not be used to describe a power tilt seating system 
or a power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees. 
These seating systems must be coded as A9900 and are not separately payable. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or 
without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests. The unit of 
service of code E1010 is a pair. The unit of service for code E1012 is each. You can find these rules in the 
Local Coverage Article Wheelchair Options/Accessories - Policy Article A52504. 
 
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.