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 say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that A manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) is covered if: 
 
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: 
 
      1.  Prevents the beneficiary from accomplishing an MRADL entirely, or 
 
      2.  Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
 the attempts to perform an MRADL; or 
 
      3.  Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
     
The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane 
or walker. 
     
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use of 
the manual wheelchair that is provided. 
     
Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it on a regular basis in the home.      
The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. 
     
The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to 
safely self-propel the manual wheelchair that is provided in the home 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. 
     
The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
 
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria: 
 
    Cannot self-propel in a standard wheelchair in the home; and 
 
    The beneficiary can and does self-propel in a lightweight wheelchair. 
 
You can find this information in the Local Coverage Determination (LCD): Manual Wheelchair Bases 
(L33788). 
 
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.