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 a power standing feature (E2301) is non-covered because it is not primarily medical in 
nature. 
 
The rules say that miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a 
specific Healthcare Common Procedure Coding System (HCPCS) code and are not included in another code 
should be coded K0108. 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 The rules say that effective for services performed on or after May 16, 2023, power seat elevation equipment is 
reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the 
following conditions are met: 
1. The individual has undergone a specialty evaluation that confirms the individuals ability to safely operate 
the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical 
professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has 
specific training and experience in rehabilitation wheelchair evaluations; and, 
2. At least one of the following apply: 
 
    a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using 
either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a 
sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of 
assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
    b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or, 
    c. The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary 
locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use 
of assistive equipment. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, 
Publication 100-03, National Coverage Determination (NCD) for Seat Elevation Equipment (Power Operated) 
on Power Wheelchairs (280.16). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.