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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 A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I
are also met.

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:

a) Prevents the beneficiary from accomplishing an MRADL entirely, or
b) Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary
to the attempts to perform an MRADL; or
c) 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.

a) 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.
b) An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight,
seating options, and other appropriate nonpowered accessories

D. The beneficiary is able to:
a) Safely transfer to and from a POV, and
b) Operate the tiller steering system, and
c) Maintain postural stability and position while operating the POV in the home.

E. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are
sufficient for safe mobility using a POV in the home.

F. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the
operation of the POV that is provided.

G. The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater
than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy Duty POV
is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a
beneficiary weighing 428 - 600 pounds.

H. Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the
beneficiary will use it in the home.

I. The beneficiary has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable
and necessary.

The rules also say that a Group 2 Single Power Option PWC (K0837) is covered if all of the coverage criteria
(a)-(e) for a PWC are met and if:

A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. The beneficiary requires a drive control interface other than a hand or chin-operated standard
proportional joystick (examples include but are not limited to head control, sip and puff, switch
control).
2. The beneficiary meets coverage criteria for a power tilt or power recline seating system (see
Wheelchair Options and Accessories policy for coverage criteria) and the system is being used
on the wheelchair.
3. 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.
4. 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.

You can find these rules in the Local Coverage Determination (LCD) for 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.