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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 Power Mobility Device (PMD) bases require a Standard Written Order (SWO) prior to 
delivery. The SWO may also list all associated options and accessories that are billed separately. Refer to this 
LCDs related Policy Article for more information. 
 
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. 
 A Group 1 power wheelchair (PWC) (K0813, K0814, K0815, K0816) or a Group 2 PWC (K0820, K0821, 
K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) 
for a PWC are met and the wheelchair is appropriate for the beneficiarys weight. 
 
A POV or PWC which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or 
which has been reviewed by the PDAC and found not to meet the definition of a specific power operated 
vehicle (POV)/PWC will be denied as not reasonable and necessary and should be coded as K0899.  
 
An SWO is required prior to claim submission for all options, accessories, and/or supplies that are separately 
billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by someone 
other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for separately 
billed options, accessories, and/or supplies, a treating practitioner must review and sign the order. 
 
The treating practitioner who reviews and signs the SWO for separately billable options, accessories, and/or 
supplies does not need to be the same treating practitioner who completed the written order prior to delivery 
(WOPD) for the PMD base and conducted the face-to-face encounter. In this situation, the treating practitioner 
who orders the options, accessories, and/or supplies must: 
 
Verify that a qualifying face-to-face encounter occurred within 6-months prior to the date of the WOPD for the 
base item; and, 
Have documentation of the qualifying face-to-face encounter that was conducted for the base item; 
Review and sign their order. 
 
Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site 
evaluation of the beneficiarys home to verify that the beneficiary can adequately maneuver the device that is 
provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a 
written report of this evaluation available on request. 
 
You can find these rules in the 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.