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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 state that codes E2310 and E2311 describe the electronic components that allow the beneficiary to
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or
non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power
leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the
beneficiary to select the motor that is being controlled and an indicator feature to visually show which function
has been selected. When the wheelchair drive function has been selected, the indicator feature may also show
the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for
fixed mounting hardware for the control box and for the display box (if present).
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and
with complete replacement of the expandable controller. Code K0108 must not be used for any component or
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual
components of the harness are replaced, code K0108 should be used.
power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not
primarily medical in nature.
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable
speed programmability; a switch control which is independent of the power wheelchair drive control interface.
You can find this information in the Local Coverage Article Wheelchair Options/Accessories - Policy Article
(A52504).The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are
clearly used for medical purposes. Medicare will not pay for:
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers and electric air cleaners;
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.
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.