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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 Group 3 power wheelchair can be covered only for enrollees who have a mobility
limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices L33789.
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:
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power
Mobility Devices LCD; and
2. 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 beneficiary's seating and positioning needs.
The PT, OT, or practitioner may have no financial relationship with the supplier; and
3. 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.
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a
functional weight shift; or
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to
independently transfer from the wheelchair to bed; or
6. 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.
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.
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.
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.
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).
You can find this information in Medicare's Local Coverage Determination (LCD): Wheelchair
Options/Accessories (L33792) and 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.