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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 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). 
 
The rules state that all of the following basic criteria (A-C) must be met for a power mobility device 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 criteria 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 PWC. 
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. 
 
A Group 3 PWC with Single Power Option (such as code K0856) is covered if: 
All of the coverage criteria (a)-(e) for a PWC are met; and 
The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity; and 
Criterion 1 or 2 is met; and 
Criteria 3 and 4 are met. 
The beneficiary requires a drive control interface other than a hand or chin-operated standard proportional 
joystick. 
The beneficiary meets coverage criteria for a power tilt or a power recline seating system and the system is 
being used on the wheelchair. 
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. 
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. 
 
If the base power wheelchair is not covered, all related accessories will also be denied. You can find these rules 
in 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.