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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.
All of the following basic criteria (A-C) must be met for a power mobility device (K0801), or a push-rim
activated power assist device (E0986) 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:
o Prevents the beneficiary from accomplishing an MRADL entirely, or
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality
secondary to the attempts to perform an MRADL; or
o 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.
o 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.
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device
weight, seating options, and other appropriate nonpowered accessories.
POWER OPERATED VEHICLES (K0800, K0801, K0802, K0806, K0807, K0808, K0812):
A Power Operated Vehicle (POV) is covered if all of the basic coverage criteria (A-C) have been met and if
criteria D-I are also met.
D. The beneficiary is able to:
o Safely transfer to and from a POV, and
o Operate the tiller steering system, and
o Maintain postural stability and position while operating the POV in the home.
E. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision)
are sufficient for safe mobility using a POV in the home.
F. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for
the operation of the POV that is provided.
G. The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and
greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy
Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered
for a beneficiary weighing 428 - 600 pounds.
H. Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the
beneficiary will use it in the home.
I. The beneficiary has not expressed an unwillingness to use a POV in the home.
If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable
and necessary.
You can find this rule in the Centers for Medicare and Medicaid Services, 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.