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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 all of the following basic criteria (A-C) must be met for a power mobility device (K0842) 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. 
 
If the power wheelchair (PWC) base is not covered, then related accessories will be denied. You can find this 
information in the Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 
The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating leg rests 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. 
 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find this information in the Local Coverage Determination (LCD) for 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.