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 state 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. 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. 
 
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 criteria 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 
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. 
 
If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not 
reasonable and necessary. A Group 3 PWC with Multiple Power Options (such as K0861, K0862, K0863, 
K0864) is covered if: 
A. All of the coverage criteria (a through e) for a PWC are met; and 
B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. Criteria 1 or 2 (below) is met; and 
D. Criteria 3 and 4 (below) 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, 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 practitioner may have no financial relationship with the supplier. 
4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering 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. 
 
If the PWC base is not covered, then related accessories will be denied. You can find these rules in Local 
Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
The rules state 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; 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 these rules in 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.