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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 a Group 3 power wheelchair (PWC) with multiple power options is covered if: 
A. All of the coverage criteria for a PWC are met; and 
B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
C. The beneficiary has had 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 and that documents the medical 
necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, 
OT, or practitioner may have no financial relationship with the supplier; and 
D. 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. 
E. Criteria 1 or 2 (below) is 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. 
 
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 say 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 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 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). 
 
The rules say that power seat elevation equipment may be covered when at least one of the following apply: 
a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, 
using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower 
extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; 
or, 
c. The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in 
customary locations within the home. MRADLs may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment. 
You can find this rule in the Medicare National Coverage Determinations Manual, 280.16 Seat Elevation 
Equipment (Power Operated) on Power Wheelchairs (Rev. 12183, Issued:08-03-23, Effective:05-16-23, 
Implementation:09-04-23 
 
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.