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 effective for services performed on or after May 16, 2023, power seat elevation equipment is 
reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the 
following conditions are met: 
 
1. The individual has undergone a specialty evaluation that confirms the individuals ability to safely operate 
the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical 
professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has 
specific training and experience in rehabilitation wheelchair evaluations; and, 
2. At least one of the following apply: 
a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, 
using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower 
extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; 
or, 
c. The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in 
customary locations within the home. MRADLs may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment. 
You can find this information in the Centers for Medicare & Medicaid Service, Internet-Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Seat Elevation Equipment 
(Power Operated) on Power Wheelchairs (280.16). 
 
The rules say that a power standing feature (E2301) is non-covered because it is not primarily medical in 
nature. You can find this information in 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 patients 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 & 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.