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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 all of the following basic criteria (A-C) must be met for a power mobility device or a push-
rim activated power assist device 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. 
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. 
 
A Group 3 power wheelchair (PWC) with Single Power Option is covered if: 
A. The Group 3 criteria IV(A) and IV(B) are met; and 
IV(A) All of the coverage criteria for a PWC are met; and 
IV(B) The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity 
B. The Group 2 Single Power Option (criteria II[A] and II[B]) are met. 
II[A]. Criterion 1 or 2 is met; and 
II[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 (examples include but are not limited to head control, sip and puff, switch control). 
   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 Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789).  
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 
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 
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. 
 
You can find this information in the 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.