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 All of the following basic criteria (A-C) must be met for a power mobility device (K0800, 
K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, 
K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, 
K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, 
K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, 
K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898) 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: 
        * Prevents the beneficiary from accomplishing an MRADL entirely, or 
        * Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
        * Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
    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. 
        * 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. 
        * 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 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: 
        * Safely transfer to and from a POV, and 
        * Operate the tiller steering system, and 
        * Maintain postural stability and position while operating the POV in the home. 
         E. The beneficiarys 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 beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
    G. The beneficiarys 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 beneficiarys ability to participate in MRADLs and the 
beneficiary will use it in the home. 
    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 information in the Local Coverage Determination (LCD) 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.