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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 an expandable controller is capable of accommodating one or more of the following 
additional functions: 
 
- Other types of proportional input devices (such as, mini-proportional or compact joysticks, touchpads, chin 
control, head control, and so on) 
- Non-proportional input devices (such as, sip and puff, head array, and so on) 
- 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 (for example, for alternate control devices) 
- Other electronic devices (such as, control of an augmentative speech device or computer through the chair's 
drive control) 
- An attendant control 
 You can find this rule in Local Coverage Article: Power Mobility Devices - Policy Article (A52498) - Effective 
January 1, 2020. 
 
The rules say that miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a 
specific Healthcare Common Procedure Coding System (HCPCS) code and are not included in another code 
should be coded K0108. 
 
Each power wheelchair code is required to include a lap belt or safety belt on initial issue (that is, no separate 
billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be 
separately billed does not necessarily indicate coverage. 
 
The rules say that a Column II code (such as code E0978) is included in the allowance for the corresponding 
Column I code (such as code K0861) when provided at the same time. 
 
You can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy 
Article (A52504). 
 
The rules say that there is no separate payment for mounting hardware for a seat or back cushion. 
 
The rules say that a headrest (E0955) describes any type of cushioned headrest which may contain one or more 
cushions to position the head and fixed mounting hardware. 
 
You can find this information in the Local Coverage Article: Wheelchair Seating - Policy Article (A52505). 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.