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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). 
 
The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0861) 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 nonpowered accessories. 
 
A power operated vehicle (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 percent 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. 
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. 
If a POV will only be used outside the home, see related Policy Article for information concerning 
noncoverage. 
 
POWER WHEELCHAIRS (K0861): 
 
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 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 percent 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 beneficiarys 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 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. 
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: 
 
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 physical therapy (PT) or occupational therapy (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 Multiple Power Options (K0861) 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 these rules in Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
The rule say that a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, 
E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a 
beneficiary who meets both of the following criteria: 
 1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the 
beneficiary meets Medicare coverage criteria for it; and 
2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
 
a. A diagnosis code listed in Group 2 of the International Classification of Diseases (ICD)-10 code list in the 
LCD-related Policy Article; or 
b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 
 
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note 
special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the 
LCD-related Policy Article.) 
 
A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or 
fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt 
and/or recline power seating system. 
 
You can find these rules in Local Coverage Determination (LCD) Wheelchair Seating (L33312). 
 
The rule say POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, 
E1006, E1007, E1008, E1009, E1010, E1012): 
 
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: 
 
1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
2. 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 of the 
beneficiarys seating and positioning needs. The PT, OT, or practitioner may have no financial relationship 
with the supplier; and 
3. 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. 
4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
6. 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. 
 
POWER SEAT ELEVATION SYSTEM (E2300) 
 
A power seat elevation system will be covered if a beneficiary meets the coverage criteria for either a Group 2 
single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair 
as described in the Power Mobility Devices LCD and meets the coverage criteria for seat elevation equipment 
as described in CMS Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03) Chapter 1, 
Part 4, Section 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs. 
 
If these criteria are not met, the power seat elevation system will be denied as not reasonable and necessary.  
 Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a 
power wheelchair. One example (not all-inclusive) of a covered indication for swingaway, retractable, or 
removable hardware (E1028) would be to move the component out of the way so that a beneficiary can 
perform a slide transfer to a chair or bed. 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.