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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 person's 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 that 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 beneficiary's 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 that 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 beneficiary's 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 beneficiary's 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 beneficiary's 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 a PWC will only be used outside the home, see related Policy Article for information concerning 
noncoverage.  

A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power 
Options (K0861, K0862, K0863, K0864) is covered if:  
A. The Group 3 criteria IV(A) and IV(B) are met; and 
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] 
and III[B]) (respectively) are met. 

If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. 

For beneficiaries who do not have special skin protection or positioning needs, a power wheelchair with 
Captain's Chair provides appropriate support. Therefore, if a general use cushion is provided with a power 
wheelchair with a sling/solid seat/back instead of Captain's Chair, the wheelchair and the cushion(s) will be 
covered only if either criterion 1 or criterion 2 is met: 

1. The cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair 
model - i.e., codes K0839, K0840, K0843, K0860, K0861, K0862, K0863, K0864, K0890, K0891; or 
2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided. 
If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion 
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 rule in Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
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.