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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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say all of the following basic criteria (A-C) must be met for a power mobility device (K0861) 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: o Prevents the beneficiary from accomplishing an MRADL entirely, or 
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
o 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. 
o 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. 
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device 
weight, seating options, and other appropriate nonpowered accessories. 
 
The rules also say 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. 
 
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. 
 
If the PWC base is not covered, then related accessories will be denied. 
 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules say that up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are 
allowed if required for a power wheelchair. 
 
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 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. 
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. 
 
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware 
(E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a 
chair or bed. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories 
(L33792). 
 
The rules say a sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable 
from a power wheelchair base. 
 
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. However, if individual 
components of the harness are replaced, code K0108 should be used. 
  
An expandable controller is capable of accommodating one or more of the following additional functions: 
 Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
 Non-proportional input devices (e.g., sip and puff, head array, etc.) 
 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 (i.e., for alternate control devices) 
 Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
 An attendant control 
 
A power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat platform and a solid back; 
any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or 
swingaway detachable leg rests; fixed or flip-up footplates; two motors and related electronics with or without 
variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a 
headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from 
horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 
inches; ability to support beneficiary weight of at least 250 pounds. 
 
Code E1028 is used for 
1.  
1. Swingaway hardware used with remote joysticks or touchpads, 
2. Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, 
and 
3. Swingaway hardware for an indicator display box that is related to the multi-motor electronic 
connection codes E2310 or E2311. 
 
Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because 
swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a 
wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes 
swingaway hardware. 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. 
 
You can find this information in the Local Coverage Article (LCA): Wheelchair Options/Accessories 
(A52504). 
 
The rules say a custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom 
fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 
1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated 
seating system is not sufficient to meet the beneficiarys seating and positioning needs. The PT or OT 
may have no financial relationship with the supplier. 
 
If a custom fabricated cushion is provided for a beneficiary who does not meet the stated coverage criteria, it 
will be denied as not reasonable and necessary. 
 
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 International Classification of Diseases (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 the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
The rules say that for a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added 
to the code only if criterion (a) is met and criterion (b), (c), or (d) is met: 
a. For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical 
professional, such as a PT or OT (who has no financial relationship with the supplier) which explains 
why a prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning 
needs; and 
b. For E2609, there is a past history of, or current, pressure ulcer in the area of contact with the seating 
surface; or 
c. For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an 
inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis 
for skin protection cushions; or 
d. For E2609 or E2617, the beneficiary has significant postural asymmetries due to one of the diagnoses 
listed as a covered diagnosis for positioning cushions 
 
In addition to meeting the specific requirements listed above, for all seat and back cushions and positioning 
accessories, the KX modifier must be added to the code only if the item is being used with a wheelchair that 
meets coverage criteria specified in the Manual Wheelchair Bases or Power Mobility Devices LCD. 
 
For a headrest (E0955), a KX modifier must be added to the code only if one of the coverage criteria specified 
in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD has been met. 
 
For a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, 
E2620, E2621), or positioning accessory (E0953, E0956, E0957, E0960), a KX modifier must be added to the 
code only if the beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered 
diagnosis in Group 2 or Group 3 of the ICD-10 code list section. 
 
You can find this information in the Local Coverage Article (LCA): Wheelchair Seating (A52505). 
 
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.