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. 
 
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. 
The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately 
fitted cane or walker. 
 
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 WHEELCHAIRS (K0013, 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): A power wheelchair (PWC) is covered if: 
 
1. All of the basic coverage criteria (A-C) are met; and 
2. The beneficiary does not meet coverage criterion D, E, or F for a power operated vehicle (POV); and 
3. Either criterion J or K is met; and 
4. Criteria L, M, N, and O are met; and 
5. Any coverage criteria pertaining to the specific wheelchair type (see below) are met. 
The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
 
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 
 
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. 
 
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
 
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. 
 
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. You can find these rules in the Local Coverage Determination (LCD) Power 
Mobility Devices L33789. 
 
The rules say that 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 legrests; 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. 
 
A power tilt seating system or power tilt and recline seating system which does not achieve a tilt of greater than 
or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair. Codes 
E1002, E1003, E1004, E1005, E1006, E1007, E1008 must not be used to describe a power tilt seating system 
or a power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees. 
These seating systems must be coded as A9900 and are not separately payable. 
 
A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior 
back panel reclines or raises there is a mechanical linkage between the two panels which allows the 
beneficiary's back to stay in contact with the anterior panel without sliding along that panel. 
 
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the 
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with 
the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests. The unit of 
service of code E1010 is a pair. The unit of service for code E1012 is each. 
 
A power seat elevation system (E2300) includes: a motor 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 must provide a seat elevation of 
at least 6 inches. 
 
A power standing feature (E2301) is non-covered because it is 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 standing feature, it will be denied as non-covered. 
 
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.) 
 
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. 
 
The interfaces described by codes E2312, E2321, E2322, E2325, E2327, E2328, E2329, E2330, E2373, E2374, 
E2375, E2376, E2377 must have programmable control parameters for speed adjustment, tremor dampening, 
acceleration control, and braking. A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a power 
wheelchair base. You can find these rules 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.