Appeal type: unknown
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 (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. 
 
A power wheelchair is covered if: 
All of the basic coverage criteria (A-C) are met; and 
The beneficiary does not meet coverage criterion D, E, or F for a (power operated vehicle (POV); and 
Either criterion J or K is met; and Criteria L, M, N, and O are met; and 
Any coverage criteria pertaining to the specific wheelchair type (see below) are met. 
The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
 
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 
 
The beneficiarys 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 power wheelchair 
(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. 
 
The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
 
Use of a power wheelchair will significantly improve the beneficiarys 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. 
 
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. You can find these rules in the Local Coverage Determination (LCD) Power 
Mobility Devices L33789. 
 
The rules say that a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, 
E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a 
beneficiary who meets both of the following criteria: 
 
The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary 
meets Medicare coverage criteria for it; and 
 
The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
 
A diagnosis code listed in Group 2 of the code list in the LCD-related Policy Article; or 
 
A diagnosis code listed in Group 3 of the code list in the LCD-related Policy Article. 
 
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note 
special instructions for a combination skin protection and positioning cushion in the code list in the LCD-
related Policy Article.) 
 
A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or 
fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt 
and/or recline power seating system. You can find these rules in the Local Coverage Determination (LCD) 
Wheelchair Seating L33312. 
 
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.