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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 all of the following basic criteria (A-C) must be met for a power mobility device or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
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:
o Prevents the beneficiary from accomplishing an MRADL entirely, or
o Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
o 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.
o 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.
o An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.
POWER OPERATED VEHICLES (K0800, K0801, K0802, K0806, K0807, K0808, K0812): A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.
D. The beneficiary is able to:
o Safely transfer to and from a POV, and
o Operate the tiller steering system, and
o 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. Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. If a POV will only be used outside the home, see related Policy Article for information concerning noncoverage. POWER WHEELCHAIRS: A power wheelchair is covered if:
a. All of the basic coverage criteria (A-C) are met; and
b. The beneficiary does not meet coverage criterion D, E, or F for a POV; and
c. Either criterion J or K is met; and
d. Criteria L, M, N, and O are met; and
e. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
J. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or
K. 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
L. The beneficiary's 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 - 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.
M. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
N. Use of a power wheelchair will significantly improve the beneficiary's 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.
O. 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. If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage. ADDITIONAL CRITERIA FOR SPECIFIC TYPES OF POWER WHEELCHAIRS:
I. A Group 1 PWC (K0813, K0814, K0815, K0816) or a Group 2 PWC (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary's weight.
II. A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) 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 a 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.
If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating legrests), it will be denied as not reasonable and necessary.
III. A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) 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 meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and Accessories policy) and the system is being used on the wheelchair.
2. The beneficiary uses a ventilator which is mounted on the wheelchair.
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or 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.
If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be denied as not reasonable and necessary.
IV. A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) is covered if:
A. All of the coverage criteria (a)-(e) for a PWC are met; and
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
C. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or 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; and
D. 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.
If a Group 3 PWC is provided and if criteria (IV)(A) - (IV)(D) are not met, it will be denied as not reasonable and necessary.
V. A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met, it will be denied as not reasonable and necessary.
If the PWC base is not covered, then related accessories will be denied.
You can find this 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.