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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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
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. 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:  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. B. The 
beneficiarys 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.  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 
non powered 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: 
 Safely transfer to and from a POV, and 
 Operate the tiller steering system, and 
 Maintain postural stability and position while operating the POV in the home. 
E. The beneficiarys 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 beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces 
for the operation of the POV that is provided. 
G. The beneficiarys 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 beneficiarys 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. 
 
You can find this information in the Local Coverage Determination (LCD) 33789. 
 
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.