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 state that a Group 3 power wheelchair (PWC) with single power option is covered if: 
A. All of the coverage criteria for a PWC are met; and 
B. The beneficiarys 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 physical therapist (PT) or occupational therapist (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 Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) 
who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection 
for the beneficiary. 
E. Criteria 1 or 2 (below) is met: 
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard 
proportional joystick (examples include but are not limited to head control, sip and puff, switch 
control). 
2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system and 
the system is being used on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. You can find these rules in Local 
Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
The rules state that 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 beneficiarys 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. 
You can find these rules in Local Coverage Determination (LCD) Wheelchair Options/Accessories (L33792). 
 
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.