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, 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 (PWC) 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 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  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. 
 
A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) is covered if: The Group 3 criteria (A) and (B) are met; and The Group 2 Single Power Option are met. 
A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) 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 
 
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: 
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 (examples include but are not limited to head control, sip and puff, switch control). 
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. The PT, OT, or practitioner may have no financial relationship with the supplier. If the 
PWC base is not covered, then related accessories will be denied. You can find this information in Local 
Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices 
LCD; and 
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 of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight 
shift; or 
The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
The power seating system is needed to manage increased tone or spasticity. 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find these rules in Local Coverage Determination (LCD) Wheelchair Options/Accessories (L33792). 
 
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.