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. 
 
    A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) is covered if all of 
the coverage criteria (a)-(e) for a PWC are met and if: 
        Criterion 1 or 2 is met; and 
        Criteria 3 and 4 are 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 (see 
Wheelchair Options/Accessories policy for coverage criteria) 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 (see Documentation Requirements section). 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. 
 
    If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but 
not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power 
standing feature, or power elevating legrests), it will be denied as not reasonable and necessary. 
 
If the 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. 
 
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 this information in the 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.