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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 all of the following basic criteria (A-C) must be met for a power mobility device (PMD) 
(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. 
 
SPECIALTY EVALUATION: 
 
The specialty evaluation that is required for beneficiary's who receive a Group 2 Single Power Option or 
Multiple Power Options power wheelchair (PWC), any Group 3 PWC, or a push-rim activated power assist device is in addition to the requirement for the face-to-face encounter. The specialty evaluation provides 
detailed information explaining why each specific option or accessory  i.e., power seating system, alternate 
drive control interface, or push-rim activated power assist  is needed to address the beneficiarys mobility 
limitation. There must be a written report of this evaluation available on request. 
 
HOME ASSESSMENT: 
 
Prior to or at the time of delivery of a power operated vehicle (POV) or PWC, the supplier or practitioner must 
perform an on-site evaluation of the beneficiarys home to verify that the beneficiary can adequately maneuver 
the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. 
There must be a written report of this evaluation available on request. 
  
You can find this rule in the 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.