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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 claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say that the written order prior to delivery (WOPD) for the base item may only be written after the 
completion of the face-to-face encounter requirements. Pursuant to the Social Security Act, Title XVIII, 
Section 1834(a)(1)(E)(iv), the treating practitioner who completes the face-to-face requirements must be the 
same practitioner who writes the order/prescription for the power mobility device (PMD) (base item). 
 
The rules say that a supplier may provide a template to the treating practitioner for their use in creating the 
WOPD for the base item. Such a template may list the elements of a WOPD, but the supplier must not fill in or 
complete any of these elements. 
 
The rules say that a standard written order (SWO) is required prior to claim submission for all options, 
accessories, and/or supplies that are separately billed in addition to the base. This SWO obtained prior to claim 
submission, may be prepared by someone other than a treating practitioner. If someone other than a treating 
practitioner prepares the SWO for separately billed options, accessories, and/or supplies, a treating practitioner 
must review and sign the order. 
 
 
 
 
 The rules also say that prior to or at the time of delivery of a power operated vehicle (POV) or power 
wheelchair (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 information in the Local Coverage Determination (LCD) for 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.