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 Group 3 power wheelchair (PWC) with multiple power options (such as code K0861) is 
covered if: 
     A. All of the coverage criteria for a PWC are met; and 
     B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
deformity; and 
     C. 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 (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier; and 
     D. 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. 
     E. Criterion 1 or 2 is met; and 
          1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair 
Options and Accessories policy) and the system is being used on the wheelchair. 
          2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. You can find this information in the 
Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
The rules say that 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 physical 
therapist (PT) or occupational therapist (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 Assistive Technology 
Professional (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. 
 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD) for Wheelchair Options/Accessories 
(L33792). 
 
The rules say that an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, touchpads, chin 
control, head control, and so on) 
- Non-proportional input devices (such as, sip and puff, head array, and so on) 
- Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating 
actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
- A separate display (for example, for alternate control devices) 
- Other electronic devices (such as, control of an augmentative speech device or computer through the chair's 
drive control) 
- An attendant control 
 
You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that procedure code E2311 describes the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power 
leg elevation, power seat elevation, power standing. 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, 
E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who 
meets both of the following criteria: 1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the 
beneficiary meets Medicare coverage criteria for it; and 
2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; 
or 
b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 
A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or 
fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt 
and/or recline power seating system. 
 
You can find this information in Local Coverage Determination (LCD) Wheelchair Seating (L33312). 
 
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.