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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 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. 
B. The beneficiarys 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. 
 
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 D, E, or F for a power operated vehicle (POV); 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 beneficiarys 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 beneficiarys 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 beneficiarys 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 3 PWC with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if: 
A. All of the coverage criteria (a)-(e) for a PWC are met; and the beneficiary's mobility limitation is due to a 
neurological condition, myopathy, or congenital skeletal deformity 
B. Criterion 1 or 2 is met; and Criteria 3 and 4 are met. 
1. The beneficiary meets coverage criteria for a power tilt and recline seating system and the system is being 
used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted 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 Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary.) 
 
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 PT or 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 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. 
 
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.