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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 state that Codes E2310 and E2311 describe 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. It includes a function selection switch which allows the
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function
has been selected. When the wheelchair drive function has been selected, the indicator feature may also show
the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for
fixed mounting hardware for the control box and for the display box (if present).
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
For power wheelchairs which are capable of being upgraded to an expandable controller (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), E2377 is used if an
expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of
an expandable controller.
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.
A switch is an electronic device which turns power to a particular function either "on" or "off." The external
component of a switch may be either mechanical or non-mechanical. Mechanical switches involve physical
contact in order to be activated. Examples of the external components of mechanical switches include, but are
not limited to, toggle, button, ribbon, etc. Examples of the external components of non-mechanical switches
include, but are not limited to, proximity, infrared, etc. Some of the codes include multiple switches. In those
situations, each functional switch may have its own external component or multiple functional switches may be
integrated into a single external switch component or multiple functional switches may be integrated into the
wheelchair control interface without having a distinct external switch component. You can find this
information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).
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.