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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are 
not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or 
E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will 
be denied as non-covered. You can find this information in the Local Coverage Article (LCA): Wheelchair 
Options/Accessories  Policy Article (A52504). 
 
The rules say that all of the following basic criteria (A-C) must be met for a power mobility device (K0861) to 
be covered: 
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 and physical capabilities 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 
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. 
A power wheelchair (K0861) 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% of the weight capacity of the next lower weight class PWC 
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. 
A Group 3 PWC with Single Power Option (K0861) is covered if: 
A. The Group 3 criteria are met; and 
B. The Group 2 Single Power Option or Multiple Power Options are met. 
A Group 2 Single Power Option PWC 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. 
2. The beneficiary meets coverage criteria for a power tilt, or a power recline seating system 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. 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. 
A Group 2 Multiple Power Option PWC 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 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. 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. 
A Group 3 PWC with no power options 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. 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. 
The rules say that if the PWC base is not covered, then related accessories will be denied. 
 
You can find this information 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.