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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 the face-to-face encounter must be conducted within six (6) months prior to the order date on 
the written order prior to delivery for the power mobility device (base item). 
  
The rules also say that the report should provide pertinent information about the following elements but may 
include other details. Each element would not have to be addressed in every evaluation. 
  
       - History of the present condition(s) and past medical history that is relevant to mobility needs 
              - Symptoms that limit ambulation 
                    - Diagnoses that are responsible for these symptoms 
                    - Medications or other treatment for these symptoms 
                        - Progression of ambulation difficulty over time 
                    - Other diagnoses that may relate to ambulatory problems 
                    - How far the beneficiary can walk without stopping 
                    - Pace of ambulation 
                    - What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used 
                    - What has changed to now require use of a power mobility device 
                    - Ability to stand up from a seated position without assistance 
                    - Description of the home setting and the ability to perform activities of daily living in the home 
  
      - Physical examination that is relevant to mobility needs 
                    - Weight and height 
                    - Cardiopulmonary examination 
                    - Musculoskeletal examination 
                    - Arm and leg strength and range of motion 
                    - Neurological examination 
                            - Gait 
                            - Balance and coordination 
  The evaluation should be tailored to the individual beneficiarys conditions. The history should paint a picture 
of the beneficiarys functional abilities and limitations on a typical day. It should contain as much objective 
data as possible. The physical examination should be focused on the body systems that are responsible for the 
beneficiarys ambulatory difficulty or impact on the beneficiary's ambulatory ability. 
  
The written report of this encounter must be available upon request. 
  
If the power wheelchair (PWC) base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules say the treating practitioner may conduct the entire mobility face-to-face encounter or may refer the 
beneficiary to a licensed/certified medical professional (LCMP), such as a physical therapist (PT) or 
occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the 
face-to-face encounter. This person may have no financial relationship with the supplier. (Exception: If the 
supplier is owned by a hospital, the PT or OT working in the inpatient or outpatient hospital setting may 
perform part of the face-to-face encounter). 
 
You can find this information in the Local Coverage Article (LCA): Power Mobility Devices (A52498). 
 
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.