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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 All of the following basic criteria (A-C) must be met for a power mobility device or a push-
rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are 
listed below. 
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: 
o Prevents the beneficiary from accomplishing an MRADL entirely, or 
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
o 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. 
o 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. 
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device 
weight, seating options, and other appropriate nonpowered accessories. 
A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) is 
covered if: 
A. All of the coverage criteria (a)-(e) for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a PT or OT, or practitioner who has specific training and 
experience in rehabilitation wheelchair evaluations and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, 
or practitioner may have no financial relationship with the supplier; and D. 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. 
If a Group 3 PWC is provided and if criteria (IV)(A)  (IV)(D) are not met, it will be denied as not 
reasonable and necessary. 
 
A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power 
Options (K0861, K0862, K0863, K0864) is covered if: 
E. The Group 3 criteria IV(A) and IV(B) are met; and 
F. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria 
III[A] and III[B]) (respectively) are met. 
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 this rule at Local Coverage Determination (LCD) L33789: Power Mobility Devices (eff. 1/1/20). 
 
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.