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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 state 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 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:
- 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
B. The beneficiary's 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.
- 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 power wheelchair (PWC) is covered if:
a. All of the basic coverage criteria (A-C) are met; and
b. The beneficiary does not meet coverage criterion for a power operated vehicle; and
c. Either criterion J or K is met; and
d. Criteria L, M, N, and O are met; and
e. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
J. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is
provided; or
K. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who
is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and
able to safely operate the power wheelchair that is provided; and
L. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is
provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC -
i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty
PWC is covered for a beneficiary weighing 428 - 600 pounds; an Extra Heavy Duty PWC is covered
for a beneficiary weighing 570 pounds or more.
M. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for
the operation of the power wheelchair that is provided.
N. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in
MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or
physical impairments, participation in MRADLs may require the assistance of a caregiver.
O. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.
A Group 2 Single Power Option PWC is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard
proportional joystick.
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.
3. 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. The PT,
OT, or practitioner may have no financial relationship with the supplier.
4. 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.
A Group 3 PWC with no power options 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.
A Group 3 PWC with Single Power Option is covered if:
- The Group 3 criteria A and B are met; and
- The Group 2 Single Power Option criteria are met.
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).
Medicare 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; 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.
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.